Client-Led HIV Testing and Treatment as the Key to 90 + 90?

Test those who are at risk for HIV infection, and treat everyone who tests positive. This simplified guidance is a key takeaway from the UNAIDS 90-90-90 targets and the 2015 World Health Organization testing and treatment policy updates. While achieving this ambitious guidance would help to realize the global vision of an AIDS-free generation, there are significant challenges associated with rapid scale-up of HIV testing and treatment initiatives. These include cost, sufficient healthcare personnel, supply of test kits and medicines, and availability of high-quality and client-friendly services.

So how can projects like AIDSFree contribute to the 90-90-90 target? One key way is to increase leadership of people living with HIV (PLHIV) in testing and treatment responses. “Nothing about us without us” is a recurring theme in effective HIV program design; having those most affected guiding what works best for them may help increase scale-up. As more PLHIV start treatment earlier, it will be increasingly important to develop new ways to fit HIV services into clients’ lifestyles.

Exciting models are emerging that use expert patients to bring services closer to the community and link vulnerable community members to health facilities. PLHIV work as trained lay providers in communities delivering HIV tests, as they tend to have better access to individuals who need critical, non-medical HIV services. Despite many not having formal educational degrees in health care services, lay providers’ personal experiences and skills, including their abilities to provide peer support and insight, and to act as role models, can be incredibly effective in scaling up HIV testing.

PLHIV leaders may also participate in peer groups for people who are stable on ART, or act as community ART distribution points so that clients do not have to attend the health center for routine drug pick-up. The benefits for people on treatment include reductions in wait-times, costs associated with transport, and stigma related to picking up ART at clinics, as well as increased peer support.

Challenges remain, however, as more information is needed to fully comprehend how PLHIV-led activities can work and remain sustainable. For instance, some individuals do not always feel comfortable trusting members of their community and worry that if they do join a community group, their HIV status may no longer be private. In response to some of these challenges, AIDSFree’s Treatment Team is exploring programs that increase treatment distribution via novel approaches and are consolidating their findings into recommendations for other implementers.

Even though an increase of PLHIV involvement in HIV testing and treatment is a major step towards achieving the 90-90-90 goals, global health professionals need to remember that no single mechanism is going to work for every client, and the key is to have the right combination of options available to optimize testing and treatment. Irrespective of that mix, it is critical to have PLHIV informing, leading, and guiding next steps in the fight against HIV. The world is watching and ‘nothing about us without us’ is a critical component that needs to remain at the core of the 90-90-90 response.

Written by Malia Duffy, Melissa Sharer, Sabrina Eagan and Sabiha Ladak