Written by LINKAGES Kenya 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.
A female sex worker (FSW) and patient at Rongai Drop-in Center tested HIV positive in 2016 through the LINKAGES outreach program. “When I used to go to the Rongai Health Center, I would shiver with fear because of the crowds and having to move from one section of the hospital to another. I used to imagine being seen by other people from where we live. Since we began receiving our medication from our drop-in center, I am happy. Now, not many people know that I am coming here to take ART drugs. I just pop into the drop-in center and collect my medicine. This is much easier, more comfortable, and I no longer miss my appointments.”
LINKAGES Kenya operates in 16 counties and provides a comprehensive package of services to FSWs, men who have sex with men (MSM), and male sex workers (MSWs) to reduce new HIV infections and extend the lives of those who are HIV positive. The implementation of differentiated ART service delivery in two settings has resulted in an increase of individuals being initiated on treatment.
The first example of this success is the result of a collaboration between visiting clinicians and a drop-in center operated by Family AIDS Initiative Response (FAIR), a nongovernmental organization serving FSWs in Nakuru and Narok counties. At this drop-in center in the Rongai subcounty of Nakuru, 124 HIV-positive FSWs access services.
FAIR works with the Ministry of Health (MOH) through the Rongai subcounty hospital. HIV-positive FSWs who visit the drop-in center used to be referred there for initiation of care and treatment. Due to the constraints of distance and FSWs’ preference to access care at the drop-in center, the clinician now schedules one day a month at the drop-in center — usually to coincide with FSWs’ psychosocial support group meetings — to attend to registered FSWs and dispense ART.
Bernard Rono, a nurse at Rongai Drop-in Center, explains, “As a provider, from the time we brought ART services here, the drop-in center has become a one-stop shop to our FSWs, such that when they come for other services, like family planning or condoms, they also receive their medication. Follow-up for our clients is easier, too; they feel free to ask any questions with us… here, they know our focus is on them, and they are comfortable.”
FSWs who are stable (have been on treatment for at least a year and are adherent to medication) are seen by the clinician each quarter, whereas those who are unstable (nonadherent, recently started ART, have a regimen change, or a comorbid condition) are seen more frequently. Initially, FSWs requiring routine blood tests needed to go to the subcounty facility, but since October 2017 this has been done by the clinician at the drop-in center. The clinician transports the blood samples to the subcounty facility for testing and returns with results at subsequent visits. This differentiated service model started in November 2016 with 15 HIV-positive FSWs and now serves 50 FSWs.
In the second example, differentiated ART service delivery was integrated into existing KP focused services at drop-in centers in four counties. Before the launch of differentiated services, the drop-in centers already had health care workers providing HIV testing and screening and treatment for sexually transmitted infections (STIs). With the introduction of differentiated services, LINKAGES Kenya now provides HIV treatment for KP members at five drop-in centers run by implementing partners in four counties: Bar Hostess Empowerment and Support Program (BHESP), Health Options for Young Men on HIV, AIDS, and STIs (HOYMAS), Keeping Alive Societies Hope (KASH), and International Centre for Reproductive Health-Kenya (ICRH-K).
The MOH accredited the drop-in centers, each of which is partnered with an MOH facility within the county, through which they obtain antiretroviral (ARV) drugs and reporting tools, and receive on-the-job training and mentorship from the county health management teams. ART initiation and refills for HIV-positive KP members are done at the drop-in center. Blood samples are collected at the drop-in center and sent to the MOH facility for testing and monitoring of viral load. Results are returned within two to three weeks. Under this model, 118 FSWs and 115 MSM/MSWs are receiving ART. Numbers are expected to grow, since these four facilities are now equipped to provide this service to their communities.
The improvements are being felt on all sides. An FSW peer support leader from Rongai Drop-in Center, who has been living with HIV since 2009, describes, “I am very appreciative because before ART was dispensed in the drop-in center, my peers were difficult to manage, giving me a lot of work in supporting them with adherence. They were using medicine carelessly, and I had to go on their behalf to convince the provider to give them medication, promising to offer them support to comply with requirements. From the time ART became available in the drop-in center, my work is much easier.”
And for her part, an FSW client at Rongai Drop-in Center is “happy for LINKAGES having brought nearer to where we live ART drugs at the drop-in center. We used to dig into our pockets to get transport money to go to Rongai Health Center. When I got there, the queue would be so long and I would spend the whole day there. But since ART is now at the drop-in center, I come at my convenient time, I give out my card, am able to explain what my drug is, am well attended to without hurry, and am able to go back home to continue with my chores. I greatly appreciate this service.”