Introduction

The major problem being addressed by the Best Practice is poor HIV treatment outcomes. The intervention is addressing issues around poor adherence among people taking HIV medication, high default rates, delayed ART initiation, poor communication between recipients of care and service provides, poor family and community support systems. The Expert client intervention targets the general population of people living with HIV on ART, with a special emphasis on pregnant women, the AGYW, and men as there is sufficient evidence that those subgroups need more attention.
After someone has been initiated on ART, the expectation is his/her viral load will be suppressed leading to an increase in the quality of life and less infectious. If this fails, people will be sick at home due to opportunistic infections leading to being less productive. Currently, the death rate due to HIV is not high but chronic illness has resulted in children almost running the family. As a city, we still facing a high incidence of HIV. Data from the recency study shows that we still have a lot of new infections.

The intervention aims at improving the adherence and retention in care for people on HIV treatment. The expert clients also make sure that clients in care fully utilize available HIV services with an aim of having their quality of life improved. The fact that the intervention is using trained and experienced clients on ART, it makes it much easier for them to link and bring back those people who have been lost in care.

The intervention is working towards assisting the city to achieve its 95, 95, 95 UNAIDS treatment targets. This is being done through the following
- To facilitate HIV index testing for families and sexual partners of newly identified PLHIV
- To facilitate early linkage of clients newly diagnosed with HIV
- To bring back to care HIV clients who missed their appointments or were lost in care

The use of expert clients is key throughout the HIV treatment cascade. The same concept has yield positive results in identifying new HIV positive clients especially in the key population program. The concept is more like the global Meaningful Involvement of People living with HIV (MIPA). For the country to identify the few remaining people living with HIV not yet diagnosed, their involvement is key for re-direction in targeting. The same also applies to keeping people in care. All these efforts will have an impact in viral load suppression, the ultimate treatment goal.

Description

Activities being implemented are:
HIV index testing
– Increase awareness through one on one communication on the need and importance of index testing
– Follow up on index clients who have not yet turned up for testing
Linkages
- Identifying newly diagnosed clients that have been linked for various services, especially ART
- Provide peer counseling and psychological support
- Escorting clients for different services
Bringing clients back to Care
- Identification of clients who have missed their appointments
- Making phone calls to clients who have missed their appointment for 7days
- Making phone calls and home visits for ART clients who have missed their appointments by 14days
- Conducting home visits for defaulters
- For newly initiated clients the following, first follow up is done at 6months, expert clients will make sure VL is done, and also explain the results
Other activities include;
- Peer mentor support
- Health Education
- Adherence support
- Provider initiated testing and counseling (PITC)
This approach brings together many partners in HIV testing and treatment. This includes the Ministry of Health through the public health facilities and the ministry headquarters (Department of HIV and AIDS). The ministry of health has an active Differentiated Service Delivery Model section with a desk officer to support this service delivery model. The project is being implemented by Mothers2Mothers, being a sub-grantee of the Elizabeth Glaser Pediatric AIDS Foundation (EGPAF) with funding from USAID. The program is integrated within the Ministry of Health ART program in the public health facilities. The other partners involved include the Malawi AIDS Counseling and Resource Organization (MACRO) and Community Based Organizations within the locations. The general community is involved as the expert clients are part of the community based organizations (CBOs). CBOs are not only for people living with HIV, they have a lot of sub-groups and support groups for PLHIV is just one of them. The approach is ethical and those enrolled or targeted are still treated with dignity and their rights are respected. Most of these expert clients are also representatives from the local community based organizations.

The innovation is supported by both local and national authorities. At both levels, partners also provide technical support to the structures and also direct to the program. The expert clients are attached to partners and the ART/PMTCT focal person at the health facility. The focal person is also attached to the City/District ART/PMTCT coordinator for support. This initiative is not meant to share technical knowledge or experience but it’s a platform for those living with HIV to share their life experiences in care with an aim to encourage each other to stay on treatment.

Data Collection

Below are some of the indicators for tracing
Number of missed appointments after 14 days
Number missed appointments after 14 days Not traced up
Number missed appointments not traced after 14 days - Not traced due to absence of physical address or phone number
Total traced
Number of missed appointments after 14 days traced up physically only
Number of missed appointments after 14 days traced up by phone only
Number of missed appointments traced up physically and by phone
TOTAL TRACED
Number of missed appointment after 14 days brought back to care
Number of missed appointment after 14 days Not traced but Self brought back to care
Number of missed appointment after 14 days traced up but Self Transferred Out
Number of missed appointments after 14 days traced up but died
Number of missed appointments after 14 days traced up but stopped ART
Number missed appointments after 14 days traced up but Promised to come
Number missed appointments after 14 days found on ART due to poor adherence
Number missed appointments after 14 days found on ART due emergency supply from another facility
Number of missed appointments after 14 days traced up but Lost To Follow UP (LTF)
Total outcome

Linkage indicators include
- Number of clients linked for ART
- Number of clients linked for other HIV related services

Results, Outputs, and Outcomes

No external evaluation has been done yet but the program data is showing positive results as the number of missed appointments is reducing. In 2021 quarter 3, a total of 873 clients on ART missed their appointments by more than 14 days. The expert clients managed to trace (91%) of them either by phone (18%) or physically (75%). Through counseling, they managed to bring back to care 59.8% instantly and 26.7% promised to visit their nearest health facility later for their refill. It was also discovered that 0.5% had received emergency medication from other health facilities and 7.3% were lost to follow-up. Through the expert client program, 99.6% of those who missed their appointment by more than 14 days had clear outcomes after tracing. The project recruited 110 expert clients spread across 24 health facilities. Each health facility is allocated about US$20-30 per month for phone calls used for client tracing. Facility allocation of expert clients and airtime is based on ART patient volume. Data shows that about 18% of the clients are traced through phone calls and the remaining proportion (72%) is traced physically

Despite that this initiative has not been evaluated externally, the approach has a component of efficiency as it is targeted based on the available program data. The expert clients only target the newly initiated clients, those who missed their appointments and those who have been lost in care. For the newly initiated clients, group counseling is done and suspected clients who are most likely to miss appointments are identified for individual counseling. Examples of such clients include adolescents, men and pregnant women. Not everyone on HIV care needs direct support.

Lessons Learned

The peer support concept seems to be bringing positive results as clients also share experiences with other peers. Now there is also open communication as the expert clients have more time to talk to ART clients. Critical issues are being resolved through the specialized clinic staff. The expert clients are role models and are identified from the same community where the clients reside. This has helped to easily follow up and to identify other reasons why clients were lost in care.

The greatest challenge was enrolling expert clients who at least had completed secondary school education. These could not be found, the program had to recruit those whose educational level was below secondary education. The challenge was these people could not easily learn some of the program aspects such as report writing, and lessons in English. It slightly compromised the quality of services being provided especially during the early phase of the program. The other challenge was the ratio between expert clients and ART clients. Some high-volume sites with about 5000 clients on ART had only 10 expert clients. Sometimes expert clients could be overwhelmed with work.

If relevant, Please describe the sustainability/continuity of the best practice within the context of the COVID-19 pandemic.

In the presence of COVID-19, the program can still take place, for follow-ups, phone calls and texts can be used to remind those people who have missed their appointments. Home visits can also be done for defaulters as the expert clients live in the same community as their ART clients. Each expert client is attached to clients within his/her residential area.

The concept can be replicated as expert clients can be recruited from already existing structures and organizations such as support groups for people living with HIV, members for active PLHIV forms and those individuals who have already disclosed their status to the community. Volunteers can be drawn from the health facility ART cohort as always is the case. Because the identified individuals are already in care, minimal training is required for them to start the peer to peers experience sharing and the rest is done as mentor as the expert clients practice.

Conclusion

People living with HIV are now able to relate with expert clients and are even more open to forward their challenges through expert clients. The expert clients are now working as a bridge for communication between the specialized health providers and ART clients. Some of the barriers to accessing services have been resolved through the program.
The rate of opportunistic infections has also declined making PLHIV healthier and more productive. The long-term impact will be improved quality of life and reduction of HIV incidence within the city as more people attain viral suppression. The intervention is being considered a best practice because of its effectiveness in bringing people back to care.

This is being regarded as a best practice because the intervention is client-centered as it uses part of the target group to improve the ART program outcomes. The intervention is also addressing critical problems being faced by the ART program in cities (poor retention). The cost-benefit analysis has also proven that the program is efficient. The intervention is integrated into the Ministry of Health public health facilities and the expert clients also report to the ART nurse at the clinic.