Globally an estimated 36.7 million people are living with HIV (PLHIV). By June 2016, 18.2 million were enrolled on ART. The epidemic is not yet controlled: 2.1 million new infections and 1.1 million deaths were reported in 2015. Higher levels of ART coverage are needed to control HIV transmission and reduce mortality. Therefore, barriers to ART will need to be removed maximally. This is a major challenge, especially in sub-Saharan Africa (SSA), the region with the highest HIV prevalence. This thesis evaluates approaches which aimed at improving accessibility and utilization of the ART programme.
In Mozambique, ART decentralization was slowed down due to a shortage of health care workers and inadequate infrastructure. Moreover, distances remained a major barrier to ART. We learnt that facility-based ART would not suffice to achieve and sustain high levels of ART coverage. High attrition (defined as patients being either death or loss-to-follow-up) rates showed that successful ART provision entailed more than enrolling patients on ART.
How to bring ART delivery closer to the patient’s home? In 2008, in the rural communities of Tete province, we proposed patients stable on ART to join peer groups, and engage in community ART delivery. These peer groups were named Community ART Groups (CAG). Early and long term retention on ART in CAG was high. CAG members reported a reduction of direct and indirect treatment costs, and felt relieved by the secured supply of ART. Experiences with CAG in other provinces of Mozambique, and in Lesotho, showed that the CAG model could be transferred to other settings. However, patient participation in ART delivery doesn’t lead to a better utilization of all available health services. Although CAG members were perceived as co-providers of the ART program, surprisingly less than half of the family aggregate was tested for HIV. Moreover, mother and child health services were not well used by the CAG members and their family aggregate. On the other hand, when viral load monitoring was implemented in Maputo, the uptake of viral load monitoring was higher in CAG than in individual care.
Community engagement is increasingly recognised as an enabler of uptake, linkage, retention, and adherence. In high prevalence contexts a comprehensive package of preventive, diagnostic, and therapeutic interventions will need to be embedded in daily life. When barriers are removed and communities are motivated to use available services, HIV control may become feasible, even in resource constrained contexts.