Peer-Delivered Linkage Case Management and Same-Day ART Initiation for Men and Young Persons with HIV Infection — Eswatini, 2015–2017

To achieve epidemic control of human immunodeficiency virus (HIV) infection, sub-Saharan African countries are striving to diagnose 90% of HIV infections, initiate and retain 90% of HIV-diagnosed persons on antiretroviral therapy (ART), and achieve viral load suppression* for 90% of ART recipients (90-90-90) (1). In Eswatini (formerly Swaziland), the country with the world’s highest estimated HIV prevalence (27.2%), achieving 90-90-90 depends upon improving access to early ART for men and young adults with HIV infection, two groups with low ART coverage (1–3). Although community-based strategies test many men and young adults with HIV infection in Eswatini, fewer than one third of all persons who test positive in community settings enroll in HIV care within 6 months of diagnosis after receiving standard referral services (4,5). To evaluate the effectiveness of peer-delivered linkage case management^† in improving early ART initiation for persons with HIV infection diagnosed in community settings in Eswatini, CDC analyzed data on 651 participants in CommLink, a community-based, mobile HIV-testing, point-of-diagnosis HIV care, and peer-delivered linkage case management demonstration project, and found that after diagnosis, 635 (98%) enrolled in care within a median of 5 days (interquartile range [IQR] = 2–8 days), and 541 (83%) initiated ART within a median of 6 days (IQR = 2–14 days), including 402 (74%) on the day of their first clinic visit (same-day ART). After expanding ART eligibility to all persons with HIV infection on October 1, 2016, 96% of 225 CommLink clients initiated ART, including 87% at their first clinic visit. Compared with women and adult clients aged ≥30 years, similar high proportions of men and persons aged 15–29 years enrolled in HIV care and received same-day ART. To help achieve 90-90-90 by 2020, the United States President’s Emergency Plan for AIDS Relief (PEPFAR) is supporting the national scale-up of CommLink in Eswatini and recommending peer-delivered linkage case management as a potential strategy for countries to achieve >90% early enrollment in care and ART initiation after diagnosis of HIV infection (6).

CommLink was implemented by two outreach teams, each operating with a van in rural and urban catchment areas in the Hhohho and Manzini regions of Eswatini during June 2015–March 2017 (Figure 1). Each team included two or three HIV-test counselors, three HIV-positive, ART-adherent expert client (peer) counselors, and a nurse. HIV testing was offered to persons encountered at homesteads, worksites, bars, and high-traffic urban locations (e.g., near markets and bus stops). Clients who tested positive and had not received HIV care in the past 90 days were offered point-of-diagnosis HIV care and linkage case management. In modified vans (mobile units) parked at test locations, CommLink nurses provided physical and psychosocial assessment, clinical staging, CD4 count, syndromic treatment for sexually transmitted infections, and a 7-day course of cotrimoxazole (Figure 2). Medical files completed by CommLink nurses were transferred within 48 hours to clinics, health centers, and other referral facilities where clients could receive ART (Figure 1).

Peer counselors provided linkage case management for consenting clients from the time of diagnosis through at least the first return visit for facility-based care after ART initiation. For ART-eligible clients who did not initiate ART or return for their first refill of antiretroviral medication, linkage case management services continued for up to 90 days. Linkage case management comprises the package of services recommended by CDC^§ and the World Health Organization (WHO), including 1) peer-delivered counseling and psychosocial support; 2) treatment navigation at referral facilities (escorting to or meeting clients at the referral facility at least once, providing psychosocial support [for the duration of the first clinic visit], and explaining the content, sequence, and locations of HIV clinical, laboratory, and pharmaceutical services); 3) weekly telephone calls and appointment reminders; and 4) two follow-up face-to-face counseling sessions on disclosing HIV status to and HIV testing of partners and family members and on identifying and resolving real and perceived barriers to HIV care (1,7).

National guidelines for ART eligibility based on CD4 count were expanded twice during the project, resulting in the following three ART-eligibility periods: 1) June 2015–November 2015 (CD4 count <350/µL); 2) December 2015–September 2016 (CD4 count <500/µL); and 3) October 2016–March 2017 (any CD4 count, Test and Start^¶). At referral facilities, same-day ART patients received a 14-day supply of antiretroviral medications and were instructed to return in 2 weeks to receive their baseline laboratory test results and their first 30-day antiretroviral refill. Information on receipt of facility-based clinical services, including ART, and associated dates of service were abstracted from patient health care cards.

Among 909 persons who tested HIV-positive during CommLink outreach events, 21 (2%) left the event before eligibility screening, and 163 (18%) were either currently in HIV care (90), requested a referral to a facility outside of the catchment area (33), or were ineligible for linkage case management for other reasons, such as residence in another region or country (40). Among 725 eligible persons, 19 (2.6%) were aged <15 years and were excluded from analyses. Of 706 eligible persons aged ≥15 years, 651 (92%) participated in linkage case management and received services for a median of 42 days (IQR = 24–66 days).

Excluding weekly telephone contacts, >90% of clients in all demographic and diagnostic subgroups, including men, persons aged 15–29 years, participants from urban outreach events, and participants who had counselors of a different gender, received linkage case management services (Table). Although proportionally fewer male than female counselors documented weekly telephone contacts with their clients, male counselors contacted 236 (99.6%) of their 237 clients by phone at least three times.

From the date of diagnosis, 635 (98%) clients received HIV care at least once at a referral facility within a median of 5 days (IQR = 2–8 days), and 541 (83%) initiated ART within a median of 6 days (IQR = 2–14 days), including 402 (74%) on the day of their first clinic visit (Table). As ART eligibility increased from a required CD4 count <350/µL to Test and Start, the percentage of all clients initiated on ART increased from 66% to 96%, the percentage of clients initiated on ART who received same day ART increased from 62% to 87%, and, among 361 clients with newly diagnosed HIV infection, the median CD4 count at ART initiation increased from 313/µL (IQR = 203/µL–422/µL) to 454/µL (IQR = 264/µL–598/µL). Among 402 clients who initiated ART on the day of their first clinic visit, 379 (94%) returned to the facility at least once after ART initiation within a median of 14 days (IQR = 14–15 days).

Nearly all clients enrolled in facility-based HIV care, including men (97%), persons aged 15–29 years (97%), participants from urban (97%) and rural (98%) outreach events, and participants with counselors of the same or different gender (95%–99%). Compared with women and adult clients aged ≥30 years, similar high proportions of men and clients aged 15–29 years received same-day ART and returned to care after same-day ART initiation (Table).

Corresponding author: Duncan MacKellar, dmackellar@cdc.gov, 404-639-6199.

¹Division of Global HIV and TB, Center for Global Health, CDC; ²Population Services International Country Program, Mbabane, Eswatini; ³National AIDS Programme, Eswatini Ministry of Health, Mbabane, Eswatini; ⁴CDC Country Office, Mbabane, Eswatini.

References

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FIGURE 1. CommLink* catchment areas and referral HIV-care facilities — Eswatini,^† June 2015–March 2017

Abbreviation: HIV = human immunodeficiency virus.

* CommLink is a community-based, mobile HIV-testing, point-of-diagnosis HIV care, and peer-delivered linkage case management demonstration project.

^† Formerly Swaziland.

The figure above is a map of Eswatini showing CommLink catchment areas and referral human immunodeficiency virus–care facilities located in Eswatini during June 2015–March 2017.

FIGURE 2. CommLink* outreach testing with point-of-diagnosis HIV-care services — Eswatini,^† June 2015–March 2017

Abbreviation: HIV = human immunodeficiency virus.

* CommLink is a community-based, mobile HIV-testing, point-of-diagnosis HIV care, and peer-delivered linkage case management demonstration project.

^† Formerly Swaziland.

The figure above consists of three photographs showing CommLink* outreach testing with point-of-diagnosis human immunodeficiency virus–care services in Eswatini during June 2015–March 2017.

Abbreviations: ART = antiretroviral therapy; HIV = human immunodeficiency virus; IQR = interquartile range; LCM = linkage case management.
* CommLink is a community-based, mobile HIV-testing, point-of-diagnosis HIV care, and peer-delivered LCM demonstration project.
^† Formerly Swaziland.
^§ Duration of CommLink services: median interval = 42 days, IQR = 24–66 days.
^¶ Includes clinical assessment, CD4+ T-cell count/µL (CD4 count) testing, syndromic treatment for sexually transmitted infections, and cotrimoxazole preventive therapy provided by CommLink nurses at HIV diagnosis.
** Client accompanied by CommLink peer counselor for the duration of at least the first HIV-care facility visit and received psychosocial support and informational counseling on the content and location of HIV clinical, laboratory, and pharmaceutical services.
^†† Client spoke with peer counselor, on average, at least once per week for the duration of CommLink services.
^§§ Client received initial and at least two follow-up face-to-face counseling sessions focused on the importance of early enrollment in HIV care and ART, disclosure to and HIV testing of partners and family members, and identifying and resolving real and perceived barriers to enrollment or retention in HIV care.
^¶¶ Documentation on patient’s health care card of receipt of HIV care services at least once at a standing fixed facility (clinic, health center, or hospital). Median interval from HIV diagnosis to enrollment in HIV care = 5 days (IQR = 2–8).
*** ART initiation among patients who met national eligibility guidelines is not provided because of observed variation in ART initiation practices across facilities attributed to 1) a Test and Start study conducted at multiple northern facilities and 2) facility-specific interpretation of expanding national treatment guidelines. Percentages are of all CommLink clients. Median interval from HIV diagnosis to ART initiation = 6 days (IQR = 2–14).
^††† Initiated during the first facility visit. Typical practice is to provide a 14-day starter pack of antiretroviral medication. Percentages are of patients initiated on ART.
^§§§ Returned for HIV care at the facility at least once after same-day ART initiation; median interval from ART initiation to return visit = 14 days (IQR = 14–15). The return visit was typically to receive baseline test results and the first 30-day antiretroviral medication refill. Percentages are of patients initiated on ART.
^¶¶¶ Client reported a prior HIV diagnosis but not having received HIV care in >90 days.
**** Changes in national ART polices based on CD4 count; Test and Start = ART for all HIV-infected persons regardless of CD4 count.