Background: Despite improved access to antiretroviral therapy (ART), many people living with HIV (PLHIV) in sub-Saharan Africa, particularly those tested in community settings, continue to delay enrollment in care following HIV diagnosis. To enroll >90% of PLHIV within three months of diagnosis, we implemented a peer-delivered, linkage case-management (LCM) program providing WHO recommended linkage services.
Description: Conducted in Bukoba Municipality Tanzania (population: ~150,000) as part of a larger combination prevention evaluation, LCM was provided to clients who tested HIV-positive at 11 health facilities (facility clients), and at homes or community events in 14 urban and rural wards (community clients). LCM services were provided by HIV-positive, peer counselors for up to 90 days. During Test & Start, LCM was combined with same-day ART initiation for both facility and community clients.
Lessons learned: Of 4,805 eligible persons, 4,273 (89%) consented to LCM. Of 4,206 (98%) clients with complete indicator data, most received recommended services: counseling on early enrollment in care (100%); escort to HIV clinic (83%); treatment navigation (94%); telephone support (77%), and in two separate sessions, counseling on disclosure and partner/family testing (77%); and on real and perceived barriers to care (69%). Enrollment in HIV care and ART initiation within three months of diagnosis increased over time, exceeding 95% and 85% during Test & Start, respectively, for both facility and community clients (Table). During Test & Start, 98% and 97% of males (n=310) and females (n=442), and 96% and 98% of clients aged 15-24 (n=150) and 24-49 (n=535) years, respectively, enrolled in HIV care. Of 463 clients who participated in the last three months of the roll-out of Test & Start, 91% were initiated on ART. Per-client LCM service cost was $54 USD.

 All clientsFacilityCommunity
Client Characteristicsnn (%)n (%)nn (%)n (%)nn (%)n (%)
Total42063918 (93)2521 (60)35383367 (95)2247 (64)668551 (82)274 (41)
ART-eligibility periods:         
Oct 2014 - Dec 2015 (CD4<350)22332018 (90)1057 (47)18761738 (93)971 (52)357280 (78)86 (24)
Jan 2016 - Sep 2016 (CD4≤500)12211168 (96)815 (67)10311013 (98)732 (71)190155 (82)83 (44)
Oct 2016 - Mar 2017 (Test & Start)752732 (97)649 (86)631616 (98)544 (86)121116 (96)105 (87)
[Enrollment to HIV care and ART initiation in different ART-eligibility periods]

Conclusions/Next steps: WHO-recommended peer-delivered LCM services achieved early ART initiation for the majority of both facility and community clients in Tanzania at modest cost, and was more successful when combined with same-day ART. In Tanzania, peer-delivered LCM was approved by the Ministry of Health as a new service delivery model in 2017 and is being adopted for national implementation in 2018 by three PEPFAR-supported HIV-prevention and treatment organizations.

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