How a national intervention in Botswana improved same-day ART initiation for people newly diagnosed with HIV

Image by RTI International/Ruth McDowall. Creative Commons licence.

Fifty-nine percent of adults started ART on the same day as HIV diagnosis, and 78% within seven days following a national intervention to improve rapid ART initiation in Botswana, researchers from the Botswana-University of Maryland School of Medicine reported in the journal AIDS.

Strategies deployed during the programme included recruiting, training, and assigning facility health workers and peers as ‘fast-track champions’, extension of clinic hours, making medication starter packs available, and co-ordinating ART linkage between facilities and communities.

The intervention

To reduce the risk of patients being lost to care before starting ART, the World Health Organization recommends rapid initiation of ART within seven days following a confirmed HIV diagnosis and the offer of same-day ART initiation for those who are ready. In February 2019, the Botswana Ministry of Health and Wellness, working with PEPFAR, issued a national guidance document entreating implementing partners to adopt the Reboot programme. One of the programme’s key areas was improving same-day and fast-track (within seven days) initiation of ART following HIV diagnosis.

The Reboot programme was rolled out in 41 high-volume health facilities across 11 districts of Botswana. Each facility had over 1000 clients on ART treatment.

Glossary

linkage to care

Refers to an individual’s entry into specialist HIV care after being diagnosed with HIV. 

opportunistic infection (OI)

An infection that occurs more frequently or is more severe in people with weakened immune systems, such as people with low CD4 counts, than in people with healthy immune systems. Opportunistic infections common in people with advanced HIV disease include Pneumocystis jiroveci pneumonia; Kaposi sarcoma; cryptosporidiosis; histoplasmosis; other parasitic, viral, and fungal infections; and some types of cancer. 

virological suppression

Halting of the function or replication of a virus. In HIV, optimal viral suppression is measured as the reduction of viral load (HIV RNA) to undetectable levels and is the goal of antiretroviral therapy.

Fifty-one facility clinicians were identified, recruited, and trained across the facilities to act as fast-track champions. The champions spearheaded the Reboot program in their facilities and monitored weekly data on same-day or seven-day ART initiation. Also recruited from surrounding communities were peer counsellors who were willing to share their HIV status and experience, were virally suppressed, and had completed a three-day training on HIV counselling.

The peer counsellors contacted clients on the day of diagnosis, provided information on the importance of same-day ART initiation, and accompanied the client to their first visit. They also encouraged clients to be engaged with their HIV care, offered psychosocial support, and, when needed, transitioned clients to other facilities where they intended to continue their ART care. Clinic hours were extended during the intervention to increase access to HIV services.

"The peer counsellors contacted clients on the day of diagnosis and accompanied them to their first visit."

For clients diagnosed in departments not adequately prepared to support those in need of ART (e.g., outpatient, maternity, emergency departments), an initial treatment course of 14–30 days was made available as part of the starting process. Peer counsellors followed up with clients who were continuing HIV care outside ART facilities within the first 14 days following diagnosis. They confirmed that the clients successfully transitioned to an ART-facility for ongoing care. The ART facilities also confirmed that newly transferred clients had attended at least one clinical visit.

For individuals who were not linked to ART within 72 hours and did not have underlying medical conditions which could delay ART initiation, facility health workers collaborated with community health workers in tracing and contacting clients to assist with scheduling appointments. For newly identified HIV-positive individuals with other health conditions or opportunistic infections (e.g., tuberculosis), the facility case manager followed up with the client.

Outcomes

To determine the outcome of this intervention, Dr Milton Montebatsi from the Botswana University of Maryland and colleagues conducted analysis using data from 5,822 eligible newly HIV-positive individuals aged 18 years or older. A total of 2,269 had tested HIV-positive before the Reboot was implemented (October 2018 to January 2019), and 3,553 tested positive during the first few months of Reboot (February 2019 to September 2019).

Among those who were tested before Reboot, 28% were initiated on the same day of testing and 56% were initiated within seven days of testing.

During Reboot, 59% of clients started ART on the same day of testing and 78% within seven days of testing.

There was no difference by sex for either same-day or seven-day initiations. However, younger age groups were more likely to start treatment on the same day and within seven days than older age groups.

Dr Milton Montebatsi told aidsmap.com that despite Covid-19 mitigation measures which interrupted health service delivery, Reboot data up to December 2021 showed that increased same-day linkage was sustained.

Conclusion

“Our evaluation suggests that a national intensive multi-component intervention contributed to improving timely ART initiation among newly identified HIV positive in Botswana,” the researchers conclude.

“Identifying and implementing different client-centred strategies under a comprehensive framework to facilitate ART initiation is critical to preventing AIDS-related complications and preventing ongoing transmission.”

References

Montebatsi M et al. Improving same-day antiretroviral therapy in Botswana: effects of a multifaceted national intervention. AIDS 36: 533-538, 2022.

DOI: 10.1097/QAD.0000000000003139

Full image credit: Fighting NTDs in Cross River State, Nigeria. Image by RTI International/Ruth McDowall. Available at www.flickr.com/photos/rtifightsntds/35590031472 under a Creative Commons licence CC BY-NC-ND 2.0.