Task-shifting for viral suppression: piloting a provider-peer case management approach to support unsuppressed people living with HIV (PLHIV) at Wantanshi Health Center (CS) in the Democratic Republic of Congo (DRC)

BACKGROUND: DRC's estimated viral suppression rate is 87.4% (2020), highlighting the need to focus on viral suppression. However, limited facility personnel and weak monitoring mechanisms hamper delivery of comprehensive support for PLHIV to achieve viral suppression. The USAID/PATH Integrated HIV/AIDS Project in Haut-Katanga (IHAP-HK) supported Wantanshi CS to introduce a collaborative case management system to better support PLHIV achieve suppression (<1000 copies/mL).
DESCRIPTION: IHAP-HK co-created a collaborative case management system with Wantanshi CS, PLHIV, and peer educators by: 1) conducting empathy mapping to understand PLHIV pathways to viral suppression; 2) defining a minimum service package with quality standards; 3) advocating for task-shifting to peer educators; and 4) training providers on the service package and monitoring tools (unsuppressed PLHIV register; service monitoring dashboard). A clinical provider-peer educator pair would contact PLHIV with unsuppressed viral load (VL) within seven days to develop and implement a customized plan, with enhanced adherence counseling tailored to self-identified barriers, close monitoring, and use of reminder systems. We report viral suppression outcomes of 51 PLHIV who received detectable VL results between September 2019 and September 2021.
LESSONS LEARNED: Median age of these PLHIV was 37 years (IQR: 28'44), and 53% were female. Most common reasons cited for treatment nonadherence were forgetfulness (49%), competing priorities (24%), and travel (18%). Among the 51 PLHIV, 44 (86%) received undetectable VL counts after four months of customized case management, and seven (14%) after 12 months. A defined service package and task-shifting to peers enabled consistent delivery of high-quality services, and led to earlier enrollment in the system (four days on average versus 1-3 months at their next clinical appointment). Use of service monitoring dashboards also helped provider-peer educator pairs track service provision against established quality standards. By September 2021, 98% of PLHIV were on a dolutegravir-based regimen from 80% at initial VL sampling.
CONCLUSIONS: Our results highlight the feasibility of using this collaborative case management system to improve viral suppression outcomes for unsuppressed PLHIV at Wantanshi CS. Scaling up collaborative approaches to support PLHIV is critical to maximizing use of existing resources to help people achieve optimal health outcomes and reach viral suppression targets.

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