The Community HIV Epidemic Control Model: a community-based intervention to achieve 90-90-90 via comprehensive HIV differentiated service delivery in rural communities in Zambia


BACKGROUND: Novel HIV differentiated service delivery models are needed to help Zambia achieve 90-90-90 epidemic control. University of Maryland Baltimore (UMB) designed and implemented the Community HIV Epidemic Control (CHEC) model to support HIV testing services (HTS), linkage to antiretroviral therapy (ART), and support viral load suppression (VLS).
DESCRIPTION: UMB implemented the CHEC model under the Stop Mother to Child HIV Transmission (SMACHT) project from 2015 to 2020 (Figure 1). Via health facilities, community health workers (CHW) were recruited and trained in HTS, and psychosocial and adherence counselling. CHWs conducted community HTS, escorted clients to initiate ART, and delivered ART to patients who were stable-on-care (SOC), defined as on ART for >12 months with a suppressed viral load and willing to receive ART at home.

LESSONS LEARNED: In the first year of CHEC implementation, HTS increased from 21,051 in 2015 to 71,289 clients in 2016; 29% were tested in the community by CHWs (up from 0%).
From 2015 to 2020, SMACHT provided HTS to 1,379,387 clients, of whom 46,138 were identified as HIV positive for a positivity yield of 3.3%. Of these, 41,366 were linked to ART, 90% linkage overall.
A February 2017 sub-study of all SOC patients found that of 1,091 clients, 97% were virally suppressed with near 100% retention in care. By 2020, 66,841 clients on ART had received a VL test and 60,694 were suppressed, 91% viral load suppression.
CONCLUSIONS: By task-shifting HIV service delivery into the community, CHEC achieved 90% ART linkage and 91% VLS, with 97% VLS among SOC clients. Community-based programs can increase uptake of HTS and linkage to care. However positivity yields may be low, necessitating targeted strategies such as index testing. In home delivery of ART to SOC patients supports adherence and results in high levels of VLS.