Significant improvements have been made worldwide in terms of people receiving antiretroviral therapy (ART), but the reality remains that 3 in 5 people living with HIV are not receiving ART .
Let’s look at the numbers and the strategy of community based ART, and how EQUIP provides this as a core programmatic service to to help countries realise their UNAIDS 90-90-90 targets.
The Numbers: People Receiving ART
At the end of 2013, 12.9 million people were receiving ART globally. In the same year, the percentage of people with HIV receiving ART rose to 37% (up from 10% in 2006) (1). Of the 35 million people globally living with HIV at the end of 2013, 22 million people—3 in 5 people living with HIV—were not accessing ART.
Sub-Saharan Africa has the lion share of the HIV/AIDS epidemic, accounting for 24.7 million (or 71%) of the global total of people living with HIV. Each country varies significantly, but treatment access is at 37%, the same as it is globally. A total 87% of people living with HIV in the region who know their HIV status are receiving ART.
Knowing this context, it is therefore critical that EQUIP supports countries remove barriers to testing and knowing one’s status is critical. Equally important are continuous efforts to improve how people living with HIV are linked to treatment, as well as supported to remain in care and continue treatment once it has begun.
Community-based service delivery has been an integral part of the response to HIV. To meet the UNAIDS targets to end the AIDS epidemic by 2030, adapting ART delivery systems to meaningfully include community-based services will be essential. These community systems must be resourced and scaled up, but achieving scale requires more than that: it demands a transformation in how community-based services are linked and integrated with health systems.
Where health systems face a shortage of clinical staff, community-based service delivery can share the load and create increased efficiency through improved linkages and synergies. The models of community-based ART delivery presented here move beyond conventional systems through the strong involvement of communities along the continuum of care.
As national, provincial and district teams address the various challenges in ART delivery, mapping out existing models of ART delivery by different stakeholders and documenting good practices at the community level can support scale-up and the adaptation of models to local contexts. Effective models should then be included in national treatment guidelines.
No single approach exists for community ART delivery, and different approaches have been developed in sub-Saharan Africa. Models need to be adapted to their context in recognition of a number of factors, such as barriers to access and retention in care, the extent of service decentralization and task shifting, the availability of safe and simple ART regimens, health service capacity, and regulatory or logistical constraints on ART delivery. More importantly, models of care need to be relevant, appropriate and responsive to the needs of people living with HIV.
Most community-based ART delivery models, however, demonstrate:
- Reduced burdens for patients and the health system.
- Increased retention in care.
- Lower service provider costs.
The success of community ART models depends on sufficient, reliable support and resources, including a cadre of lay workers, a flexible and reliable medication supply, access to quality clinical management and a reliable monitoring system for patient care (ideally including viral load). The models also require ongoing evaluation and further adaptation in order to reach more patients who are at high risk of loss to follow-up.
With thanks to UNAIDS
Community Based ART is provided in the following EQUIP supported countries: