Male-Friendly Clinics in Lesotho: Demand Creation Targeting HIV-Infected Men to Access Comprehensive Health Services

Through the support of the United States Government’s President’s Emergency Plan for AIDS Relief (PEPFAR), Elizabeth Glaser Pediatric AIDS Foundation (EGPAF) introduced comprehensive men’s clinics at selected high-volume health facilities in order to scale-up the Test and Start approach among HIV-infected men. The men’s clinics provide a male-friendly environment that encourages men to get tested for HIV, and therefore be identified as HIV positive and linked to HIV care and treatment services.  This is an effort to improve service uptake among men in Lesotho, as currently only 71% of HIV-positive males know their status, compared to 81.5% of HIV-positive females (LePHIA, 2017). These clinics provide an alternative service delivery model for adult males who are less likely to be reached by provider-initiated and community-based HIV testing approaches that are widely used in Southern Africa.

What was the problem?

Even though men are less likely to utilize existing health facility-based HIV services, they account for a significant proportion of new HIV infections and subsequent onward transmission. As a result, men were getting fewer benefits from the newly introduced Test and Start approach, which will potentially compromise Lesotho’s ability to reach the 90-90-90 targets by 2020. Treatment coverage among men living with HIV aged 15-59 years is 63% compared to 74% among their female counterparts (LePHIA, 2017). In line with the revised national ART guidelines, differentiated models of HIV testing, care and treatment services targeted at men needed to be introduced to address this gap in Lesotho’s HIV program.

What is the solution?

EGPAF worked in collaboration with the Ministry of Health (MoH) to design a program targeted at scaling up access to comprehensive HIV services for men.  Baseline focus group discussions were held to obtain an understanding of what ‘male-friendly’ services would entail. Using lessons learnt from this assessment, EGPAF identified space in existing government health facilities to establish male friendly clinics.  Male nurses and counselors were recruited and trained. These male staff would provide services to men in an environment where men felt comfortable. This was done in order to address the barriers to men accessing health services, including provision of extended clinic hours for those unable to access clinics during normal working hours.

What was the impact?

Data for the first 11 months for the eight men’s clinics established in June 2017 are shown above (Figure 1).  Of 36,793 visits, 23,823 were either known to be HIV positive or had a recent negative HIV test (ineligible for testing). Therefore 12,970 men were eligible for HIV testing, of whom 98% or 12,753 consented to be tested.  The HIV testing yield was 13.5%.  Linkage to treatment for those found to be positive was 120%.  This high linkage was possible as some men previously known to be positive came to the men’s clinics to initiate treatment.  Thus, the number initiated on treatment actually exceeded the number of men newly diagnosed.  

 Figure 1. Summary data on EGPAF Men’s Clinics on number of men HIV tested, tested HIV-positive, and initiation on ART, June 2017 - April 2018 (including transfers initiated on ART).

Figure 1. Summary data on EGPAF Men’s Clinics on number of men HIV tested, tested HIV-positive, and initiation on ART, June 2017 - April 2018 (including transfers initiated on ART).

 Table 1. Number of men HIV tested, tested HIV-positive, and initiated on ART June - December 2017 at Men’s Clinics, shown in 5-year age bands.

Table 1. Number of men HIV tested, tested HIV-positive, and initiated on ART June - December 2017 at Men’s Clinics, shown in 5-year age bands.

How does it work?

Systems and services level

Male friendly clinics leverage existing infrastructure to provide a separate space, or in some cases dedicated times, to allow only men to access primary health care services.  This is intended to address sociocultural barriers impeding men from visiting health care facilities, since Basotho men primarily view services at health units as for women and children only.  The client-focused services in the men’s clinics offer programmatic benefits that include flexible appointment schedules, longer working hours, service delivery by staff trained in providing male-friendly services, multi-disease consultations, one-stop-shop for consultation and drug dispensing (e.g. ARV drug refills), short waiting times, and focus on male health care needs. 

Local Environment

Having a local “Champion” to support the program is important to building interest and demand. In Lesotho, the Principal Chief, who is a member of Senate, has endorsed the initiative. He has also advocated for scaling up men’s clinics for the benefit of quality health services for all men in the country. Ensuring that all chiefs organize meetings for the health team in their catchment areas can help create demand and build momentum. Sensitization of communities on the availability of services through radio interviews (provided free of charge on local radio) was shown as an effective way to get men to attend clinics. Public gatherings that allow the health departments to educate people about health information can also create a favorable local environment.

National Environment

National level leadership, coordination and oversight for this intervention was through the Director of Sexual and Reproductive Health and the Director of Disease Control in the MoH.  Expansion of male clinics had been identified as one of the priority interventions in the draft National HIV/AIDS Strategic Plan, which facilitated initiation.  For sustainability, it is critical to have the government involved and committed to staff these clinics.

As this program expands, discussions are underway with the MoH, District Health Management Teams, and EGPAF to identify male nurses that could be re-assigned to male clinics, and ensure targeted service providers are adequately trained in the provision of male-friendly health care services.  In addition, the program is investigating whether the use of female nurses in the male clinics will affect uptake of services.

Scalability

The male friendly clinics were initiated as a pilot beginning in June 2017.  After 6-months, the country team observed high HTS yield (>10%) in males 20-49 years old, and over 100% linkage to treatment in males 25-50+ years old. 

As a result, male friendly clinics began scaling-up at 9 additional sites in three scale-up districts. These sites are expected to be fully operational by September 2018.  Furthermore, 8 additional sites will be stood-up in select sustained districts.  Sustainability of the initiative will be strengthened through the use of MoH staff to provide services in the male clinics.

Management & Oversight

Monitoring:

Implementation fidelity and quality was monitored through monthly partner performance reviews, program monitoring site visits, and Site Improvement through Monitoring Systems (SIMS).   The following Monitoring, Evaluation, and Reporting (MER) indicators were used create a men’s clinical cascade to monitor the progress of each site: HTS, HTS_POS, TX_NEW, and TX_CURR. Additional indicators that were used to monitor the implementation included viral load uptake and suppression rates, TB diagnostic cascade, VMMC referrals and STI screening and management.  .

BUDGET

Cost of innovative solution: 

Lesotho mens clinics_figure 3-1.jpg

The above costs are based an analysis of the partner expenditure data during the first six months of men’s clinics.   These include the fully loaded personnel costs for providing a comprehensive service package to men attending the clinics. Costs were categorized based on the staff cadre and whether they were HIV- or non-HIV related services.  HIV-related services account for 80% of the total service package.  The professional counselor expenditures were attributed to HIV testing, and the nurse clinician expenditures were attributed to ART initiation services.   This analysis was limited to ART enrolment only, and not costs related to on-going care for men currently on treatment.