Accelerating HIV epidemic control in Benue state, Nigeria, 2019–2021: the APIN program experience

Introduction: As at 2019, Nigeria was ranked the fourth highest HIV burden in the world. There is varied geographical HIV prevalence in Nigeria. The progress made is inequitable across geographical locations and sub-populations (18). Benue state has the second highest HIV prevalence in Nigeria. In 2018, about 35,623 people living with HIV (PLHIV) were yet to commence antiretroviral treatment (ART) in the state, accounting for an estimated ART coverage gap of 11% out of the combined gap of 320,921 in the country. To close this gap, the Benue ART surge (BAS) was implemented. The aim of this study was to describe the BAS strategic approaches and demonstrate progress in expanding ART access for PLHIV in Benue State, Nigeria. Methods: BAS was implemented in 252 health facilities from May 2019 to September 2021. Data were collected and reported using an Excel-based dashboard and electronic medical records. The trend of HIV case identification, ART initiation, viral load suppression rate, and rate of interruption in treatment during the BAS period was then described and analyzed. Results: Out of 893,462 clients reached, 6.7% (n = 60,297) were diagnosed with HIV and 99.8% (n = 60,236) were initiated on ART. HIV case identification per month increased by 467% from 650 at baseline to a peak of 3685 in August 2020, and then declined by 35% to 2380 in September 2021. All new HIV-infected patients (100%) were linked to ART. Viral load testing coverage and viral load suppression rate increased from 30% (43,185/126,004) and 84% (n = 36,165/43,185) at baseline to 95% (n = 193,890/204,095) and 96% (185,785/193,890), respectively. Conclusion: Implementation of the BAS improved access to comprehensive HIV services in Benue State. The increase in HIV case identification and ART initiation significantly reduced the HIV treatment gap in the state. To fast track the attainment of UNAIDS 95-95-95 goals, lessons learnt from the BAS should be adapted and scaled up in the national HIV program in Nigeria.

Benue State has the second highest prevalence and burden of HIV in Nigeria. It has a statewide HIV prevalence of 4.9% with an estimated burden of 184,745 PLHIV. It is one of the seven states that account for 50% of estimated PLHIV, with ART coverage gap of 35,623 out of the combined gap of 320,921 (11%).4 In the context of HIV/AIDS, epidemic control is defined as the critical point reached where the total of new HIV infections falls below mortality from all causes among PLHIV, with both indices declining.6 UNAIDS declared a 95-95-95 target in December 2020 for year 2025. That entails that 95% of PLHIV know their HIV status, 95% of those diagnosed with HIV receive sustained antiretroviral therapy and 95% of those on ART achieve viral suppression.7 The implementation strategy of the Benue ART surge was anchored on the Incident Command System (ICS) and State Surge Consortium. The ICS is a flexible stable model for responding to large-scale events as the chain-of-command helps communication and implementation.8 There was a structured command system from CDC to APIN team led by incident commanders, and other focal persons. The ICS was supported by a decentralized operational structure with state and local government area (LGA) team approach to make programmatic decisions that are data-driven, real-time, tailored to local context; and facilitate a bottom-top approach to program management. BAS consortium was formed and launched on 25 February 2020 to collaborate between State Government, PEPFAR, community-based organizations (CBOs), and the private sector to galvanize support to achieve the targets. The surge consortium was to ensure enabling environment, ownership, and sustainability of HIV program in the state, elimination of ART-associated user fees so as to improve access, provide platforms for sourcing additional support for the surge, such as commodities/rapid test kits, garner support for expanded case finding and support public information dissemination and awareness creation. A state HIV consortium was formed for the rapid scale up of ART, which required stakeholder participation, coordination, and resource mobilization and alignment. The coronavirus disease 2019 (COVID-19) epidemic in Nigeria threatened to disrupt the progress of the Benue ART Surge. To overcome service disruption due to COVID-19, a series of adapted strategies for all PLHIV populations were implemented in February–September 2020.9,10 This was used to identify LGA-level ART gaps for targeted HIV intervention. Small area estimation (SAE) is a model-based estimation that uses pre-existing survey data, such as NAIIS and program data.11 SAE helped prioritize LGA-level testing and resource allocation. A volume analysis and tiering of facilities providing HIV services was conducted in order to map facilities to enhance optimal performance in case finding. Tier 1 and 2 sites constituted 80% of client load with suboptimal and optimal performance, respectively, in terms of weekly case-finding targets. All the other facilities in the remainder of 20% formed tier 3. To improve case finding, the HIV risk stratification tool (HRST) was deployed across different testing streams within the facility to assess HIV infection risk and to increase the likelihood of identifying PLHIV. Dedicated community teams were deployed to conduct HIV education, screening, counseling, and testing in the communities because optimization of HIV testing in the facility could not solely deliver on the recalibrated case-finding targets. The testers and linkage coordinators were also motivated by applicable performance-based incentives (PBIs) to enhance their outputs. Key population (KP) friendly CBOs were engaged to provide population-sensitive community testing services using high yielding and efficient HIV testing modalities. This was in collaboration between private clinics, laboratories, delivery homes, pharmacy, and patent medicine vendors for case identification and linkage. The strategy focused on readiness to start treatment and employed a multidisciplinary approach to treatment retention. Case management was instituted to ensure close follow-up within the first 3 months of ART, which is critical to long-term continuity of treatment (CoT). This made use of the 90-day adherence calendar. Other strategies included pre-emptive measures to reduce missed clinic appointments (patient education, structured appointment system, appointment reminder, scale up of differentiated service delivery models and patient satisfaction surveys),12,13 improved identification of missed appointments, client tracking after missed appointment and documentation of tracking outcomes, peer support and champions to support adherence counseling and linkage to support groups and leveraging technology for the delivery of client centric care. Viral load was optimized in consonance with achieving at least 95% viral suppression in all patients on ART as the end point of the surge. Project Extension for Community Healthcare Outcomes (ECHO) is a collaborative model of medical education and care management that is operated via remote, low-bandwidth technology to share and disseminate best practices among colleagues.14 Project ECHO and peer-to-peer learning ensured continuous quality improvement of service delivery. ECHO was deployed to all tier 1 and 2 sites. The Benue surge team conducted in person and virtual visits to selected treatment sites every month. Quality improvement approaches were used to problem-solving during such visits.12 In line with the national treatment program alignment plan toward improved resources/program efficiencies and maximum impact in the national HIV program, the Global Fund implementing partner in Benue, transited HIV service delivery with number of current PLHIV receiving ART of 13,475 to APIN by January 1, 2021. APIN successfully set up structures and processes for implementing daily program monitoring in Benue state. The system also entailed strengthening real-time data capture into the electronic medical records (EMRs) with daily national data repository (NDR) data uploads. Multimonth Dispensing (MMD) is a programmatic strategy of enabling stable patients pick up drugs for up to dose of 3 months and above to reduce frequency of visits to health facilities. This is a retrospective, descriptive, analysis of program data for PLHIV in Benue State from May 2019 to September 2021. In this study, the variables of interest include HIV positivity yield refers to the proportion of patients who tested positive among those that were tested for HIV. Linkage to ART is defined as the proportion of newly identified HIV-positive patients that were initiated on ART. Treatment current (TX_CURR) is the number of adults and children currently receiving ART. Interruption in treatment (IIT) is defined as the number of ART patients (who were on ART at the beginning of the quarterly reporting period or initiated treatment during the reporting period) and then had no clinical contact since their last expected contact. Viral load coverage (TX_PVLS (D) is the percentage of viral load eligible ART patients with a viral load test result, while viral load suppression (TX_PVLS (N) is the percentage of ART patients with a suppressed Viral Load (VL) result (<1000 copies/ml) within the past 12 months. Data on the number of clients tested for HIV, diagnosed with HIV, and commenced on ART into the surge reporting dashboard were collected. At the end of every week, the reports were validated and extensively triangulated with all source documents. This validated report is then collated from all the 252 supported facilities using a mobile data collation form. This helped to improve the timeliness of reporting and reduced transcription errors. Data was aggregated at the state level for weekly reporting to the CDC using the excel-based dashboard. The weekly surge indicators captured in paper-based Data Capturing Tools (DCTs), EMR outputs and the NDR data were triangulated for concurrence. This was further analyzed using Excel-based analytics tool to monitor performance and compare the numbers of patients who were tested, newly identified HIV positive clients and initiated on ART during the ART surge implementation. The Benue State Surge team data leads reviewed and submitted daily facility and community data for error checks and made requisite corrections in consultation with site staff. A full-scale community testing stream was activated in November 2019. Community testing efforts were tracked in a separate Excel-based tool. The Excel tool provides a weekly and monthly display of aggregate data to show progress from November 2019 to September 2021. The Benue surge team tracked numbers of individuals screened for HIV risk using the HRST, tests done, positive individuals found, and treatment initiations on a daily basis. All variables were investigated using univariate analysis to determine the frequency, distribution, tables, and charts. Independent sample t-test was employed to compare the number of HIV-positive cases and the number linked to ART between the first year (May 19–April 20) of implementation and the second year (May 20–April 21). All analysis was conducted using Microsoft Excel and STATA version 16 statistical package and statistical significance was established at 5%. APIN Public Health Initiatives is a leading non-governmental organization (NGO) that focuses on the provision of prevention, care and treatment services to patients with diseases of public health significance such as HIV/AIDS, Tuberculosis and Malaria. APIN also provides technical assistance to relevant government agencies to strengthen the delivery of Reproductive Health, Maternal, Newborn and Child Health, Laboratory services. The vision is to become the leading Public Health NGO committed to disease burden reduction and impact mitigation in Nigeria and Africa. While the mission is to provide cutting-edge, innovative and sustainable approaches to address diseases of public health importance through effective program management, service delivery, capacity building, research, strategic information & advocacy in partnership with other stakeholders. The APIN Public Health Initiatives Institutional Review Board (IRB) reviewed the study and was it determined to be exempt as non-research, public health program activity. This study required no direct contact with human participants and only utilized de-identified pooled program data that formed part of standard of care; thus no informed consent was required.15 This is reinforced by the International Ethical Guidelines for Health-Related Research Involving Humans on waiving informed consent. A research ethics committee may waive informed consent if it is convinced that the research would not be feasible or practicable to carry out without the waiver, the research has important social value, and the research poses no more than minimal risks to participants.5

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