BACKGROUND

Many existing HIV programs struggle to engage peers not already accessing services. The enhanced peer outreach approach (EPOA) complements traditional outreach by incorporating performance-based incentives linked to program milestones and working through untapped social networks to engage unidentified, hard-to-reach, and high-risk key population (KP) members—including female sex workers (FSWs)—for HIV services. The goal is to increase HIV case finding, link KP members living with HIV to treatment, and connect HIV-negative KP members with services that will help them remain negative.

EPOA was used in Burundi to increase HIV case finding by engaging existing FSW peer outreach workers (POWs) to ask other FSWs (e.g., peer mobilizers [PMs]) in their network to distribute coupons to their sexual and social contacts. The contacts were then to present the coupon for HIV testing (Figure 1). The program used both HIV-positive PMs and PMs of unknown HIV serostatus at different time points to determine which networks would be more likely to identify individuals who were HIV positive.

METHODS

EPOA was implemented with FSWs at two different time points in 2018 through the Linkages across the Continuum of HIV Services for Key Populations Affected by HIV (LINKAGES) project funded by the U.S. Agency for International Development (USAID) and the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) and led

by FHI 360. LINKAGES used the LINKAGES Enhanced Peer Outreach Approach (EPOA) Implementation Guide and Addendum (Figure 2) as a reference guide to train and lead LINKAGES teams. The first EPOA activity, in March–April 2018, engaged 100 PMs of unknown serostatus. The second EPOA activity was August–September 2018 with 38 HIV-positive PMs. Both campaigns were implemented in five provinces—Bujumbura Mairie, Bujumbura Rural, Ngozi, Kayanza, and Kirundo (Figure 3). Using routine program data, we compared the results of the two campaigns with respect to case finding and linkage to treatment.

CONCLUSIONS

Engaging HIV-positive PMs in EPOA resulted in higher case finding than engaging PMs of unknown HIV serostatus. These results demonstrate the potential added benefit of engaging HIV-positive PMs in EPOA for identifying those who are HIV positive and initiating them on treatment. The amplified EPOA model that engages HIV-positive PMs could accelerate progress toward the UNAIDS 95-95-95 goals.

Burundian Female Sex Workers: Improving HIV Case Detection by Comparing Outcomes between Recruitment Chains of HIV-Positive and Unknown-Serostatus PeersTiffany Lillie,1 Dismas Gashobotse,2 Gloriose Kamariza,2 Alphonse Nkunzimana,2 Emilie Cooper,1 Dorica Boyee3

1 FHI 360, LINKAGES, Washington DC, USA; 2 FHI 360, LINKAGES, Burundi; 3 FHI 360, LINKAGES, Africa Region

TUPEC489

ACKNOWLEDGMENTS

We would like to thank all partner organizations and their staff, volunteers, and members involved in implementing HIV programs for key populations.

This work was made possible by the generous support of the American people through the United States Agency for International Development (USAID) and the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR). The contents are the responsibility of the LINKAGES project and do not necessarily reflect the views of USAID, PEPFAR, or the United States Government. LINKAGES is

a seven-year project (cooperative agreement #AID-OAA-A-14-00045) led by FHI 360 in partnership with IntraHealth International, Pact, and the University of North Carolina at Chapel Hill.

RESULTS

In the period March–April 2018, 1,899 FSWs were tested and 82 tested positive, producing a case-finding rate of 4 percent. In August–September 2018, 345 FSWs were tested, and 34 were found HIV positive, producing a case-finding rate of 10 percent (Figure 4). Overall, 99 percent in March–April 2018 (n=81) and 100 percent in August–September 2018 who were newly diagnosed HIV positive were initiated on treatment.

0

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0

2%

4%

6%

8%

10%

12%

March - April 2018N

umbe

r of F

SWs

Cas

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82

345

34

August - September 2018

EPOA using PMs withunknown serostatus

EPOA using HIV-positive PMs

HTS_TSTHTS_TST_POSCase-finding rate

1899

Figure 4. Comparison of EPOA results using PMs of unknown HIV serostatus and HIV-positive PMs

PEPFAR

fhi360.org/LINKAGES

OBJECTIVES OF EPOA

• Close the gaps in access to testing, treatment, and prevention services among historically hidden and hard-to-reach KPs

• Improve the capacity of outreach programming to adapt to new HIV transmission patterns and continuously improve outcomes over time

• Increase the capacity of outreach programming to meet the differentiated prevention, care, and support needs of KP members in the community across the entire HIV cascade

• Improve the efficiency of, and returns on, investments in outreach programming

Peer outreach workercontacts KP members...

... and invites them to be tested forHIV, and to become peer mobilizers

Trained program worker

Contact may be known or new to program

Unknown, new contactto progarm

Unknown, new contactto progarm

Peer mobilizers contact KP members in their networks...

...and engage them to be tested for HIV, or to enroll for ART if HIV+

Peers may then in turn contact peers in their own networks for testing or treatment

RUMONGE

BUJUMBURA(MAIRIE)

BUJUMBURA- RURAL

CIBITOKE

NGOZI

KAYANZA

BUBANZA

MURAMVYA

KARUZI

KIRUNDO

MUYINGA

CANKUZO

RUYIGI

GITEGAMWARO

RUTANABURURI

MAKAMBA

FY19 GEOGRAPHICAL COVERAGE

Figure 3. Map of Burundi and LINKAGES implementation sites

RECOMMENDATIONS

• Provide incentives that motivate volunteers and do not cause volunteers to coerce those in their network to get tested for HIV.

• Ensure timely provision of incentives to POWs and PMs.

• Ensure quality by:

– Providing regular on-site mentoring to the community-based organizations and POWs

– Conducting regular data cleaning to identify errors

– Having a robust data entry system to track the more successful networks

• Analyze EPOA data on a weekly basis to track progress.

A D D E N D U M

LINKAGES Enhanced Peer Outreach Approach (EPOA)

APRIL 2019

Figure 2. LINKAGES EPOA Addendum, April 2019

Figure 1. EPOA referral chain