WHAT WAS THE PROBLEM?
Antiretroviral treatment (ART) coverage for people living with HIV (PLHIV) in Lusaka Urban District (the capital and largest city in Zambia) was estimated to be near 70 percent in January 2019, with lower coverage for children, men, and young adults. Furthermore, Lusaka has a transient population, and new HIV transmission routes can undermine the gains in treatment coverage. These challenges require innovative approaches to identify PLHIV who are less likely to seek care at traditional hospitals and ART facilities.
WHAT IS THE SOLUTION?
In March 2018, recognizing that growth in the HIV treatment program had plateaued, CoH leadership, in coordination with CRS, created a new model to identify PLHIV and immediately link to same-day ART initiation. The model has the following elements:
Decentralization of service delivery
Community mapping to identify hot spots
Each community post is staffed by a multidisciplinary team
Each community post is seamlessly embedded in a high activity and busy setting
Early and continued engagement of local stakeholders (community leaders, including faith leaders) and use of expert clients among staff and CHWs to build community trust
Continuous mentoring and feedback to community post teams to assess progress, identify barriers, and build morale
Critical elements of the model include: its acceptability by the service utilizer, the location of the community posts, the stakeholder engagement of the local community, and the selection of local CHWs who know the geographic and social terrain of the surrounding community.
WHAT WAS THE IMPACT?
After implementing the community post model, CoH saw immediate and sustained increase in HIV case identification (Figure 1). Ninety-two percent of HTS_POS from March 2018 – March 2019 reported by CoH were identified at the community posts; only 8 percent were from the central facility.
By targeting individuals at higher risk for HIV infection and emphasizing index testing for newly-identified cases, CoH has been able to achieve remarkably high yields (Figure 2). Following the introduction of community posts, unbeknownst to CoH staff, many PLHIV already on ART at other facilities in Lusaka were re-testing as a means of transferring to CoH sites, a reflection of this model’s popularity among clients. This partially explains the very high yields between May – August 2018. Upon discovery of this phenomenon, CoH re-trained testing counselors to screen for treatment transfers. This improved screening process is reflected in the testing yields from more recent months. While these yields continue to surpass the estimated prevalence in untreated PLHIV in these communities, they are not inflated due to silent transfers.
Similar to HTS_POS results, 92 percent of TX_NEW from March 2018 – March 2019 initiated ART at community posts. The new initiations of ART have resulted in impressive growth of CoH ART program (Figure 3). Of the nearly 5,600 PLHIV who initiated ART at health posts, retention in care, defined by the percentage of PLHIV initiating ART from March 2018 – March 2019 who were still active on treatment as of March 2019, was estimated at 92 percent.
In terms of identifying harder-to-reach populations, CoH has successfully reached, tested, linked, and retained adult males, adolescents, and children. Detailed testing results by age and sex show high testing yields across populations (Figure 4). This model sees particularly high yields in men ages 20 years or older.
HOW DOES IT WORK?
The community post model began with five sites, and has since expanded to 21 sites in Lusaka and eight sites in other provinces, including rural Zambia. On an individual level, the model has focused on performing risk assessments. Critically, these risk assessments begin with assessing intimate and personal characteristics that are known through trusted relationships with faith community leaders. These risk factors include things like marriage/relationship problems, recent family death or serious illness or participation in bereavement services, and participation in healing services. Identifying these risk factors will allow appropriate targeting to at-risk persons (Note: open link below to details for solution).
However, one of the challenges faced thus far is the ability to train and mentor staff in other parts of the country who can replicate this model with fidelity. There is also an emerging challenge of silent transfers, and this was discovered while investigating the high testing yields from the community posts. Viral load testing of a small sample of newly diagnosed HIV positive patients at some of the community posts found that greater than thirty percent of the patients were already virally suppressed. This indicated that they may have already been on treatment elsewhere. As differentiated service delivery (DSD) models are scaled up to help decongest health facilities, while strengthening patient transfer processes at facility-level, this should significantly reduce the impact of silent transfers. The CoH Executive Director has been a passionate advocate for scaling up this model to reach people who may be missed by current efforts due to their limited access to health facilities.
COST OF INNOVATIVE SOLUTION
The costs of this model have been kept at a reasonable level by applying lessons learned from previously offered mobile services in some of these areas. The community post model is not cost-intensive as it leverages community resources through engagement with community leadership, as described earlier. The model also has a small footprint (generally one or two small rooms in a market or bus stop) with a small contingent of six staff as described earlier. Commodities for the community post are provided through the parent health facility therefore eliminating the need for additional procurement mechanisms.
The approximate budget for each community post is listed below:
Two-to-three visits for strategic environmental scan of communities for community post site selection (fuel and other transportation costs, about $30 each trip)
Two-to-three meetings with stakeholders, community leaders, and health workers ($25 each meeting)
Select location of community post with input from community leaders and local stakeholders
Market and facility contribution (rental) for Community Posts ($80 monthly)
one clinical officer and/or nurse prescribers ($1,100 monthly salary)
one lay counsellor ($500 monthly salary)
four community health workers ($150 monthly stipend each)
Community post site renovation ($500)
Fuel ($500 monthly)
Furniture and medical supply costs for initial setup, including tables, chairs, benches, BP machines, scales (adult & pediatric), screens, stethoscopes, thermometers, curtains, consumables for 12 months ($2,000)
Support for HTS and retention outreach activities, including T-shirts, banners, "I know my status" pins, backpacks, umbrellas, bicycles, and boots ($750 annual)
Recurrent costs for HTS and retention outreach activities, including transport refunds, fuel, community sensitization, lunch for staff for each HTS point ($1,200 annual)
Timers for HTS ($15 each)
HTS SOPs: Job aids, Policy, Registers and other printed material ($130 annual)
Mobile hot spot testing pack, including standard testing supplies ($400)