Community-based health workers implementing universal access to HIV testing and treatment: lessons from South Africa and Zambia—HPTN 071 (PopART)

Abstract

The global expansion of HIV testing, prevention and treatment services is necessary to achieve HIV epidemic control and promote individual and population health benefits for people living with HIV (PLHIV) in sub-Saharan Africa. Community-based health workers (CHWs) could play a key role in supporting implementation at scale. In the HPTN 071 (PopART) trial in Zambia and South Africa, a cadre of 737 study-specific CHWs, working closely with government-employed CHW, were deployed to deliver a ‘universal’ door-to-door HIV prevention package, including an annual offer of HIV testing and referral services for all households in 14 study communities. We conducted a process evaluation using qualitative and quantitative data collected during the trial (2013–2018) to document the implementation of the CHW intervention in practice. We focused on the recruitment, retention, training and support of CHWs, as they delivered study-specific services. We then used these descriptions to: (i) analyse the fidelity to design of the delivery of the intervention package, and (ii) suggest key insights for the transferability of the intervention to other settings. The data included baseline quantitative data collected with the study-specific CHWs (2014–2018); and qualitative data from key informant interviews with study management (n = 91), observations of CHW training events (n = 12) and annual observations of and group discussions (GD) with intervention staff (n = 68). We show that it was feasible for newly recruited CHWs to implement the PopART intervention with good fidelity, supporting the interpretation of the trial outcome findings. This was despite some challenges in managing service quality and CHW retention in the early years of the programme. We suggest that by prioritizing the adoption of key elements of the in-home HIV services delivery intervention model—including training, emotional support to workers, monitoring and appropriate remuneration for CHWs—these services could be successfully transferred to new settings.

The association between HIV stigma and HIV incidence in the context of universal testing and treatment: analysis of data from the HPTN 071 (PopART) trial in Zambia and South Africa

“…Communities in each triplet were randomly allocated to three study arms. In the two treatment arms (A and B), a study‐employed cadre of community‐based health workers (HWs) known as Community HIV care Providers (CHiPs) delivered door‐to‐door HIV testing and referral services [17]. In Arm A, ART was offered to PLHIV regardless of CD4 count from the start of the trial; in Arms B and C, ART was offered according to national guidelines, which changed over the course of the trial and became regardless of CD4 count in 2016.…”

“…We used previously validated individual and community-level composite stigma measures [18]. For individual-level stigma exposures, we used three composite measures reflecting (1) perceived stigma in communities (five items) (2) perceived stigma in healthcare settings (two items) and (3) fear and judgement towards PLHIV (three items) [17]. Stigma items were pre-coded using a 4-item Likert scale ("Strongly agree" (3), "agree" (2), "disagree" (1) and "strongly disagree" (0)).…”

A screening tool enhances home-based identification of adolescents (aged 10-14) living with HIV in Zambia and South Africa: HPTN 071 (PopART) Study

“…The CHiPs recorded basic data on the household and all household members on an electronic data capture device, as well as more detailed data such as HIV test history and HIV test results of all consenting participants. Details of the PopART intervention, informed consent, and HTS are described elsewhere (13,20,22,23).…”

“…The HPTN071 (PopART) combination HIV prevention package was delivered by CHiPs via a door-to-door approach, with treatment and care-related services provided by local government clinics (22). The intervention was offered in all intervention communities (both Arm A and Arm B), eight in Zambia and six in South Africa, via three data collection rounds (see section on data collection rounds).…”

Qualitative study of patient experiences of mental distress during TB investigation and treatment in Zambia

“…In this model, patients with severe symptoms (such as suicidal ideation) are referred to specialists for more intensive support. Government commitment in providing adequate and regular training, management and sufficient remuneration is essential for such a model to be successful [ 66 , 67 ].…”