IDDT Journal

Introduction

The 2019 report from the United Nations HIV/AIDS program (UNAIDS) indicates a halving of deaths from HIV infection between 2004 and 2018, with 770,000 deaths recorded in 2018 [1]. The significant decrease in deaths compared to previous years is nevertheless a major and encouraging indicator of the success of HIV prevention and treatment strategies, primarily focused on antiretroviral therapy (ART). By the end of December 2021, 75% [66–85%] of all people living with HIV were accessing treatment. 28.7 million people had access to antiretroviral treatment, an increase of 7.8 million compared to 2010 (UNAIDS report 2021) (Placeholder1)¹.

Despite these, the decrease in the HIV related deaths, the challenges for the optimal control remain significant. Indeed, the number of new infections, estimated at 1.5 million in 2021, illustrates the sustained momentum of the pandemic and the limitations of current prevention strategies.

Advances in the development of antiretrovirals (ARV) over the past decades have made available several classes of ARV molecules, targeting different stages of the virus replication cycle, ranging from entry processes into target cells to stages of maturation of virions [2]. These advances currently make available molecules that are more potent, with reduced toxicity and higher genetic barrier to viral resistance, thereby increasing the life expectancy of persons on ARV close to that observed in the general population [3,4]. However, current therapeutic strategies do not allow the eradication of HIV in an individual and there by necessitating lifelong treatment. The development and implementation of coherent, effective, and sustainable strategies for access to ARV is essential to the success of therapeutic management. In the context of countries in the global South, the management of the infection is characterized by two essential factors, the large number of people eligible for treatment and lack of resources, nearly 26 million if the “test & treat” recommendation is applied. As a result, the definition of care strategies in this context is not always guided by known “gold standard” references, but very often by pragmatism depending on the resources available. The so-called “public health” strategy recommended by the World Health Organization (WHO) for the management of HIV infection in the South stems from these practical constraints [5].

This simplified and pragmatic strategy has made it possible to accelerate and significantly extend access to ARV in the countries of the South, by offering standard lines of first and second-line ARV, and by addressing the monitoring constraints. before initiation of ARV [6]. The benefits of increasing ART coverage in countries with limited resources are undeniable. The STRATALL trial conducted in Cameroon to assess the effectiveness of the simplified monitoring approach compared to the gold standard in resource limited settings has shown its utility as well as limitations. The high rates of first-line virological failures described in care programs in the South [8-10] quickly highlighted the limits of the strategy, in particular the lack of virological monitoring even though recommended since 2013 [11]. Despite this recommendation, access and routine use of the Viral load (VL) remain suboptimal in the majority of the countries of the South, even almost nonexistent in certain regions, in particular in landlocked areas and rural areas. The cost, stock-outs of inputs, non-prescription and other operational problems are generally associated with lack of access [12].

In Mali, the prevalence of HIV is 1.1% [13] in the general population. However, it remains concentrated in certain vulnerable groups such as men who have sex with other men (MSM) with a prevalence of 12.7% [14], i.e., around 13 times that of the general population.

Access to prevention services HIV testing ARV treatment and biological monitoring of MSM living with HIV is a real challenge in a country like Mali where these populations are highly stigmatized and subject to of violence. It is in this context that the Malian non-governmental organization (NGO) SOUTOURA, with the support of technical and financial partners, has adopted various models of differentiated services for screening, treatment, and biological monitoring for MSM through these community sexual health clinics positioned for this purpose. The main objective of this study was to assess the quality of retention on ARV treatment and access to community-based viral load services for MSM living with HIV through peer navigation and case management.

Methods

Study design and setting

The study was prospective and conducted in Bamako in Mali. The NGO SOUTOURA implemented peer navigation, positive case management and community viral load services to improve access to these services for MSM.

Peer navigation is an approach based on the use of nonprofessional peer educators who are MSM and of MSM living or not with HIV but having the necessary skills to help their peers to adhere to ARV treatment. They may or may not be HIV positive.

Focusing on retention on ARV treatment and communitylevel viral load suppression through peer navigation and case management of the cohort of MSM living with HIV supervised by the SOUTOURA non-governmental organization in Mali. SOUTOURA provides the continuum of care for MSM through three community clinics. Community clinic staff comprise of a doctor, a nurse and 20 peer navigators trained in peer navigation and case management approaches. The clinic staff provide support to MSM with HIV through therapeutic education sessions, adherence counselling and self-reliance groups with a particular focus on unstable clients.

Trained peer navigators ensure community dispensation of ART through home visits at the community clinic and/or at MSM hot spots. Each peer navigator monitors 20 PLHIV and ensures their adherence with ART treatment for up to 6 months.

Through the differentiated approaches to HIV testing, peer navigators trained in testing use rapid diagnostic tests for HIV to test all eligible MSM. If the test result is positive, peer navigators ensure that the test result is confirmed with a confirmatory test and put the person on ARV within seven days of diagnosis according to the test and treat strategy.

After 6 months of treatment, the peer navigators ensure that the MSM under ARV treatment have blood sample taken on DBS (Dried Blood Spot) for viral load testing to determine the effectiveness ART among MSM with HIV.

A case management meeting is held whenever a PLVIH has an unsuppressed viral load. This meeting involves the peer navigator and the attending physician.

During these meetings, the therapeutic education of the patient is reinforced for the adherence to the ARV treatment. The education is centered on the importance of the ARV treatment to achieve viral load suppression and how viral load suppression prevents HIV transmission. Furthermore, the risk of HIV resistance to ARV in case of poor adherence is emphasized. After these adherence support meetings, a viral load test is offered after three months.

Peer navigators also use an online platform called ORA (Online Reservation Application) which allows PLHIV to schedule an appointment for ART treatment or viral load testing.

Standard operating procedures for monitoring ART adherence, retention, viral load testing, and achieving and maintaining suppression have been implemented.

Support requires the intervention of the peer navigator and the clinician to help people living with HIV who have problems with adherence. Community viral load measurement adapts perfectly to the needs of the population who do not do not attend traditional health centers. They allow a satisfactory biological follow-up of MSM PLHIV.

Data collection and study variables

For the current study, aggregate retention and viral load data were drawn from reports generated by KOLOCHI [16] and were disaggregated by population type and age from October 2020 to September 2021. The study variables were the number and percentage of PLHIV: on ART, having stopped their treatment, dead, having been transferred; been eligible for VL, VL samples collected, results received and the rate of viral suppression.

Data analysis

Quantitative variables was described in terms of numbers and percentages. The data analysis was done with the KOLOCHI [16] health information system which contains the individual data of all patients followed by the NGO SOUTOURA. We used descriptive statistics analysis to determine the proportion of MSMs with HIV who were on ART, stopped their treatment, died, were transferred; were eligible for VL, had VL samples collected, received VL results and achieved viral suppression. The limit of viral load suppression was ≥ 1000 copies/ml according to WHO [17] recommendations.

Ethics approval and consent to participate:

This study has been approved by the Institutional Ethic committee at the Faculty of Medicine and Stomatology/ Faculty of Pharmacy at the University of Sciences Techniques and Technologies of Bamako (USTTB) and under the number 2022/199/CE/USTTB in Mali.

Results

During this period, the community clinics followed 400 MSM on ART, of which 33% (131/400) were young MSM (under 25 years of age) and 67% (269/400) were older MSM (25 years and older). All the study population were on the first line antiretroviral treatment (Tenofovir + Lamivudine + Dolutegravir). The retention rate was 90% (360/400); The retention rate was higher among young MSM (95%) than among MSM over 25 years old (87%); 38% (137/400) of MSM were deemed eligible for viral load testing, of which 84% (115/137) were tested for viral load.

77% (89/115) of MSM received their viral load result, of which 76 (85%) had a suppressed viral load result.  The suppression rate was higher in the older MSM 98% than in the younger MSM 75%.

Table 1:  Monitoring of ARV and viral load among HIV-positive MSM from the NGO SOUTOURA project in Mali using peer navigation and case management (Oct 2020 to Sept 2021).

Table 2: Monitoring of ARV and viral load among HIV-positive MSM from the NGO SOUTOURA project without peer navigation and case management (Oct 2019 to Sept 2020).