Written by LINKAGES Botswana staff.
Differentiated antiretroviral therapy (ART) delivery, a part of differentiated care, aims to improve retention and viral suppression by optimizing drug and care delivery. Models fall into four categories: health care worker-managed groups, client-managed groups, facility-based individual, and out-of-facility individual. The case studies presented in this four-part series come from the USAID– and PEPFAR-supported LINKAGES project in Botswana, Haiti, Kenya, and Malawi. They are examples of the out-of-facility individual model, sometimes referred to as the community model, and can be found in Differentiated Care for Antiretroviral Therapy for Key Populations: Case Examples from the LINKAGES Project.
“I have seen people die because of HIV, and I was hurt when I was diagnosed with HIV and told I could not be initiated on treatment because my CD4 count was high. I wondered why the nurse was not giving me treatment, why she was condemning me to death when I know many people who have been saved by antiretroviral treatment. I kept thinking of my children, asking myself, who will take care of them when I am gone? Now, I feel very healthy and confident that I will see my children grow old enough to care for themselves.” – female sex worker, Nkaikela Youth Group
LINKAGES Botswana has adopted differentiated ART service delivery to enhance links to care and treatment for two key population (KP) groups — men who have sex with men (MSM) and female sex workers (FSWs). Integrated clinical services are provided in the community through outreach at mobile clinics or drop-in centers with a one-stop-shop approach. Both HIV testing services (HTS) and ART services are offered in the same location, making it easy for those who are newly diagnosed with HIV to be immediately linked to care and treatment.
For those who are diagnosed HIV positive, the baseline laboratory tests are requested, but clients are initiated on ART immediately. An FSW from Nkaikela Youth Group recounts her experience: “I was very happy when I was told that I could get the pills [I need] same day. I could not believe it, but indeed I got my pills same day and am still taking them. I’m no longer going back and forth to the health center only to be told my CD4 count is high.”
Also, adherence counseling sessions are reduced from three sessions prior to initiation to just one, and subsequent sessions are conducted during follow-up visits. Individuals with signs of opportunistic infections or comorbidities are referred to traditional ART clinics for further evaluation.
Additionally, patients who are stable on treatment receive multimonth prescriptions and can pick up a two-month supply of medication. Clinical visits are conducted every six months but refills are done at the community level during outreach and at drop-in centers. Emergency refills for up to 14 days are available to any KP member who has missed an appointment or has traveled to another location (away from the base clinic) and can be dispensed at public health facilities or at LINKAGES-supported facilities. Nonclinical staff at drop-in centers are also trained to provide emergency refills as part of task-shifting and to allow KP individuals the flexibility of accessing treatment outside normal working hours.
“Same-day HIV testing and initiation on ART has improved the uptake of ART and reduced the number of people living with HIV who are lost to follow up. This may be attributed to the reduced number of clinic visits for adherence sessions and being flexible on the prerequisite of a treatment buddy. The one-stop model also proved to be an efficient use of time for clients when they access all essential clinical services in one visit, encouraging them to remain in treatment.” – Masego Gilbert-Lephodisa, senior technical advisor/clinical services, LINKAGES Botswana
A total of 3,477 FSWs were reached with HIV prevention services between October 2016 and September 2017. More than 81 percent of those who were eligible for HIV testing and counseling were successfully linked to testing services (n=2,831), and resulted in a 13 percent case-finding rate (n=358). Sixty-eight percent (n=242) of those who tested positive were successfully initiated on ART, an improvement of 12 percent compared to the previous year (Figure 1).
Similarly, the implementation of the one-stop-shop model in August 2016 led to an increase in the proportion of MSM who were diagnosed with HIV and who were initiated on treatment (from 38 percent in the first year to 58 percent in the second year). Therefore, same-day ART initiation in the community enhances links from HTS to enrollment into care and ART initiation among both KP groups (Figure 2). In light of this encouraging data, LINKAGES Botswana continues to scale up the differentiated model of ART delivery.