Peer Counselors Got Nearly Everyone with HIV into Care Within Days in Eswatini

In sub-Saharan Africa, only 26 to 37 percent of people diagnosed with HIV in the community who get only a standard referral enroll in care early and start antiretroviral therapy (ART). Men and young adults are the hardest to reach. In Eswatini, a project that paired each newly diagnosed person with a peer counselor living with HIV did far better: 98 percent enrolled in care, most within days.

CommLink's catchment areas and referral HIV-care facilities in Eswatini, June 2015–March 2017. Credit: CDC, Morbidity and Mortality Weekly Report.

The setting

Countries in the region aim for "90-90-90": 90 percent of HIV infections diagnosed, 90 percent of those diagnosed on ART, and 90 percent of those on ART with a suppressed viral load. Eswatini (formerly Swaziland), with the world's highest estimated HIV prevalence at the time (27.2 percent), can reach that only by getting more men and young adults onto early treatment. Community testing finds many of them, but fewer than a third of people who test positive in the community and get a standard referral enroll in care within six months.

What CommLink did

From June 2015 to March 2017, two outreach teams, each with a van, offered mobile HIV testing, care at the point of diagnosis and peer-delivered linkage case management in rural and urban areas of the Hhohho and Manzini regions. From diagnosis until at least the first return visit after starting ART — and for up to 90 days for those who had not started or not come back — peer counselors provided the package CDC and the World Health Organization recommend:

1. counseling and psychosocial support from a peer;
2. treatment navigation: escorting or meeting clients at the clinic at least once, staying with them through the first visit, and explaining where and in what order HIV clinical, laboratory and pharmacy services happen;
3. weekly phone calls and appointment reminders;
4. two follow-up sessions on telling partners and family, getting them tested, and overcoming real and perceived barriers to care.

Because counselors start at the moment of diagnosis rather than waiting for a missed appointment, they can build rapport, draw on their own experience of living with HIV, correct misperceptions about HIV and treatment, and make sure every client knows how to navigate care.

The results

Of 909 people who tested positive, 706 aged 15 and older were eligible, and 651 (92 percent) took part, for a median of 42 days.

Men (97 percent), 15- to 29-year-olds (97 percent) and clients from urban and rural events alike enrolled in care, and men and young adults started same-day ART and returned afterward at rates similar to women and older adults.

Treating everyone

Eswatini widened ART eligibility twice during the project, from a CD4 count below 350 to a threshold of 500, and then, from October 1, 2016, to everyone with HIV ("Test and Start").

People also started treatment healthier: among newly diagnosed clients, the median CD4 count at the start of ART rose from 313 to 454. Starting early prevents illness and death from HIV and transmission to partners and children.

Limits and next steps

Clinic records can contain errors, though an audit of 165 charts found the data complete and accurate. Cases closed after 90 days, so long-term retention is unknown. Better decentralized services, Test and Start and changing attitudes toward care may explain some of the gain — yet elsewhere, even when everyone diagnosed was told they would get ART, only 37 percent enrolled early with standard referral alone. The U.S. President's Emergency Plan for AIDS Relief (PEPFAR) was supporting the expansion of CommLink across Eswatini, and recommending peer-delivered linkage case management to other countries aiming for more than 90 percent early enrollment and treatment.

Sources

Based on "Peer-Delivered Linkage Case Management and Same-Day ART Initiation for Men and Young Persons with HIV Infection — Eswatini, 2015–2017," by Duncan MacKellar and colleagues (CDC; Population Services International; Eswatini Ministry of Health), Morbidity and Mortality Weekly Report, Centers for Disease Control and Prevention; a work of the United States government in the public domain.