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Beyond clinical interventions: using a community-based social work delivery approach to support viral load suppression among children living with HIV in five countries

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BACKGROUND: Global progress towards 95-95-95 targets among children living with HIV (CLHIV) remain suboptimal. In Eastern and Southern Africa, 74% of CLHIV on ART age 0-14 years are virally suppressed (UNAIDS, 2020). Pact implements PEPFAR and USAID-funded orphans and vulnerable children (OVC) programming including family-based case management for CLHIV to improve HIV clinical outcomes including viral load suppression (VLS).
DESCRIPTION: Targeting CLHIV who receive clinical services from PEPFAR-supported facilities, Pact's case management service delivery approach enables OVC and caregivers to access needs-based comprehensive social services through professional or volunteer para-social workers. This workforce supports continuity of HIV treatment through ART monitoring and counseling, disclosure support, reminders for appointments and multi-month dispensing pick-up, escorted referrals to health facilities, case conferencing with facility staff, psychosocial support, and linkages to CLHIV groups and food support. From October 2020-September 2021, Pact provided case management to 24,277 CLHIV age 0-14 years on ART with viral load results reported within the last 12 months across five countries: Tanzania (n=17,896), South Africa (n=4,489), Eswatini (n=1,314), Rwanda (n=314), and South Sudan (n=264).
LESSONS LEARNED: Among these CLHIV, 90% were virally suppressed; country results ranged 80%-98%. VLS rates varied by age group, from 85% (age <1) to 90% (age 5-9). While variations between sex within age groups were minimal (<1.5%), greater differences (>5%) were observed in Eswatini and South Sudan. CLHIV in urban areas had higher VLS rates (91%) than rural areas (88%). VLS rates among CLHIV age 0-14 in Pact's programs were higher than national UNAIDS estimates for the same age band: South Sudan (83% vs. 36%), Tanzania (91% vs. 72%), South Africa (80% vs. 70%), Rwanda (98% vs. 89%), and Eswatini (92% vs. 91%).
CONCLUSIONS: The social service sector can play an important role in pediatric VLS. CLHIV receiving case management through OVC programs have higher VLS rates compared to national estimates, yet quasi-experimental research is needed to determine the attribution of case management on VLS among CLHIV on ART. Given observed variations in VLS, OVC programs should ensure interventions are tailored to meet the needs of CLHIV as they age and transition to different ART doses and regimens.