Peer Counselors: Creating Stronger Links to Care for People Newly Diagnosed with HIV

While many community programs test and diagnose persons with HIV in sub-Saharan Africa, relatively few of those people enroll early in HIV care and initiate antiretroviral treatment (ART) following diagnosis in community settings. This is particularly true for men and young adults. Even when ART is made available to nearly all people testing positive for HIV (an approach known as Test & Start), studies continue to show that most people substantially delay enrollment in treatment following diagnosis in community settings when they receive only a referral to a clinic.

To address this issue, CDC piloted an innovative linkage program in Eswatini (formally Swaziland), a country in southern Africa with the world’s highest prevalence of HIV infection. Providing a package of linkage services recommended by CDC in 2014, the CommLink program used HIV-positive peer case managers to link clients – people newly diagnosed with HIV – to care. Between June 2015 and March 2018, four outreach teams traveled in vans throughout rural and urban areas of Eswatini, offering mobile HIV testing and counseling at homes, work places, entertainment establishments, markets, and bus stops. Clients who tested positive and needed HIV care were offered support provided by a peer linkage case manager.

Peer case managers provided psychosocial support, informational and motivational counseling, and treatment navigation services for up to 90 days. These services proved critical to getting newly diagnosed clients on ART quickly and ensuring they returned for their treatment refills. Case managers helped their clients become knowledgeable and comfortable about receiving care by escorting and staying with their clients during the first few clinic visits. During these visits, case managers introduced their clients to medical staff, explained where and what types of medical services they would receive, and provided treatment adherence counseling. Case managers helped ensure their clients stayed in care through telephone calls and appointment reminders, and by identifying and resolving real and perceived barriers to HIV care.

Peer case managers were hired from the Eswatini Ministry of Health, and their established relationships with clinic staff allowed them to effectively advocate on behalf of their clients. One case manager described a client who wanted to transfer his care to another clinic, but was denied this request by the facility. “After reporting this situation to me, I decided to approach a staff ART nurse to request help to get a transfer out of that clinic. The nurse dropped everything to prepare the transfer for the client.” Peer counselors also provided face-to-face counseling sessions to help clients disclose their HIV status to their partners and family members and even offered testing and linkage services to clients’ loved ones. Another case manager recounted a client who was hesitant to disclose his status to his partner, until the case manager suggested the three of them meet together to work on disclosing to each other. “Now they are together and they are still receiving treatment at the facility. The man thanked me for helping him and for renewing his family.”

The additional links to care and treatment services provided by the CommLink program has proven highly successful in connecting newly diagnosed people to care. From June 2015 through March 2018, 97 percent of 1,250 adult clients diagnosed in rural and urban community settings enrolled in HIV care within a median of four days. Nearly all clients enrolled in HIV care at a facility, including 97 percent of men and 97 percent of young people age 15-29 years. After Test & Start was approved in Eswatini in October 2016, of 824 CommLink clients, 97 percent initiated ART within a median four days of diagnosis, and 96 percent returned to the clinic for their first treatment refill.

Traditional programs that provide referral forms—or wait until a person has missed an appointment before following up—might miss important opportunities to help patients enroll early in HIV care. This proactive program enabled peer counselors at the time of diagnosis to build rapport, assess and understand their client’s circumstances, and tailor services to meet their client’s individual needs. What was truly innovative about this program was the ability of peer case managers to use their own personal experiences living with HIV to help clients cope with their diagnosis and understand how to navigate HIV care. These services may have been particularly helpful to men and young adults, who are, as stated previously, at the highest risk for delaying enrollment in HIV care.

The CommLink program showed that providing a package of linkage services recommended by CDC could achieve nearly universal early enrollment in HIV care and ART initiation among all persons who receive an HIV diagnosis in community settings, including men and young adults. The U.S. President’s Emergency Plan for AIDS Relief is now supporting the scale-up of this program throughout Eswatini and recommending that other countries consider peer-delivered, linkage case management as a strategy to improve early enrollment in care and ART initiation after diagnosis of HIV infection.

In Tanzania, for example, after a successful evaluation of peer-delivered, linkage case management in Bukoba Municipality, (93 percent of 4,206 clients enrolled in HIV care within 90 days of diagnosis) services were expanded to 208 health facilities in 11 regions in 2018. Tanzania plans to scale-up peer-delivered, linkage case management to approximately 1,200 facilities in all 30 regions in 2019. Cameroon also plans to pilot and scale up peer-delivered linkage case management services in 2019. The success of these programs in Eswatini and Tanzania demonstrate the value of peer-delivered linkage services and that other countries can achieve similar success.

For further information on methods and outcomes of linkage case management program evaluations, visit https://www.cdc.gov/mmwr/volumes/67/wr/mm6723a3.htm and https://doi.org/10.1371/journal.pone.0208919.