Optimizing community linkage to care and antiretroviral therapy Initiation: Lessons from the Nigeria HIV/AIDS Indicator and Impact Survey (NAIIS) and their adaptation in Nigeria ART Surge

Abstract

Background Ineffective linkage to care (LTC) is a known challenge for community HIV testing. To overcome this challenge, a robust linkage to care strategy was adopted by the 2018 Nigeria HIV/AIDS Indicator and Impact Survey (NAIIS). The NAIIS linkage to care strategy was further adapted to improve Nigeria’s programmatic efforts to achieve the 1st 90 as part of the Nigeria Antiretroviral Therapy (ART) Surge initiative, which also included targeted community testing. In this paper we provide an overview of the NAIIS LTC strategy and describe the impact of this strategy on both the NAIIS and the Surge initiatives. Methods The NAIIS collaborated with community-based organizations (CBOs) and deployed mobile health (mHealth) technology with real-time dashboards to manage and optimize community LTC for people living with HIV (PLHIV) diagnosed during the survey. In NAIIS, CBOs’ role was to facilitate linkage of identified PLHIV in community to facility of their choice. For the ART Surge, we modified the NAIIS LTC strategy by empowering both CBOs and mobile community teams as responsible for not only active LTC but also for community testing, ART initiation, and retention in care. Results Of the 2,739 PLHIV 15 years and above identified in NAIIS, 1,975 (72.1%) were either unaware of their HIV-positive status (N = 1890) or were aware of their HIV-positive status but not receiving treatment (N = 85). Of these, 1,342 (67.9%) were linked to care, of which 952 (70.9%) were initiated on ART. Among 1,890 newly diagnosed PLHIV, 1,278 (67.6%) were linked to care, 33.7% self-linked and 66.3% were linked by CBOs. Among 85 known PLHIV not on treatment, 64 (75.3%) were linked; 32.8% self-linked and 67.2% were linked by a CBO. In the ART Surge, LTC and treatment initiation rates were 98% and 100%, respectively. Three-month retention for monthly treatment initiation cohorts improved from 76% to 90% over 6 months. Conclusions Active LTC strategies by local CBOs and mobile community teams improved LTC and ART initiation in the ART Surge initiative. The use of mHealth technology resulted in timely and accurate documentation of results in NAIIS. By deploying mHealth in addition to active LTC, CBOs and mobile community teams could effectively scale up ART with real-time documentation of client-level outcomes.

Analyses of Kaposi Sarcoma trends among adults establishing initial outpatient HIV care in Nigeria: 2006–2017

“…Given the high prevalence of HHV-8 in Nigeria and the absence of effective antiviral agents or vaccines for HHV-8, timely HIV diagnosis and prompt linkage to care remains the most effective approach to reducing KS risk in the pre-ART population. HIV self-testing, which was introduced in Nigeria in 2019 [ 57 ], as well as recent interventions focused on community ART, are steps in the right direction [ 12 , 58 ]. Continued surveillance will be needed to evaluate the impact of these interventions on the KS risk among patients initiating HIV care.…”

“…The most significant gain has been improving ART coverage, which has exceeded 80% in several countries [ 11 ]. Still, prompt HIV diagnosis and linkage to care remains a weak link in the HIV care cascade in SSA [ 12 – 14 ]. While timely HIV diagnosis and prompt initiation of ART has a great impact on the occurrence of HIV-associated KS, the impact of HIV program expansion on KS risk among patients initiating HIV care in SSA remains unclear.…”

Review of antiretroviral therapy coverage in 10 highest burden HIV countries in Africa: 2015–2020

“…Besides, Nigeria's HIV/AIDS Indicator and Impact Survey was adopted (NAIIS) in 2018 with the incorporation of the community‐based organization and mobile health technology (mHealth) 14 . The community‐based organization facilitates the linkage of people living with HIV/AIDS to health facilities while mHealth was employed for monitoring and documentation 15 . The NAIIS model was reported to be more effective in the linkage and initiation of ART compared to the traditional HIV community outreach method 16 …”

“…14 The community-based organization facilitates the linkage of people living with HIV/AIDS to health facilities while mHealth was employed for monitoring and documentation. 15 The NAIIS model was reported to be more effective in the linkage and initiation of ART compared to the traditional HIV community outreach method. 16 Furthermore, the Community ART Groups (CAG) strategy has also been tested and proven by a 2020 pilot study to be effective in Nigeria.…”

Effect of Test and Treat on clinical outcomes in Nigeria: A national retrospective study

“…In Nigeria, the UNAIDS HIV 95-95-95 target achievements were estimated to be 46.9%, 96.4%, and 80.9% at the end of 2018 [ 4 ]. The large gap in the first 95 led to large scale Surge efforts in Nigeria to find people living with HIV who did not know their status and link them to care [ 5 ]. By 2020, the country had moved closer to achieving the UNAIDS HIV 95-95-95 goal with an estimated 90% of all people living with HIV identified and 90% of all people living with initiated on ART [ 6 ].…”