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This piece was originally featured on the Population Services International blog. By Daniel Crapper, Madagascar Country Representative, PSI.
While 0.3% of Madagascar’s population aged 15-49 lives with HIV, the number of HIV cases is on the rise, particularly among vulnerable and highly stigmatized groups like sex workers, men who have sex with men and people who inject drugs.
Historically, HIV testing and treatment services were exclusively available through the public sector, which these stigmatized groups typically do not find very welcoming. Despite considerable effort and resources deployed through community-based prevention services to identify and refer at-risk individuals to public clinics for HIV testing, many would refuse to attend due long distances, inconvenient opening hours, or the fear and shame of being recognized. It was a major barrier to Madagascar achieving its goals under the UN’s 95-95-95 targets to end AIDS by 2030.
With support from the Global Fund, Population Services International (PSI) focuses on some of the biggest challenges to service uptake by taking a differentiated delivery approach to reach the populations most exposed in zones of vulnerability. Through the MDG-H-PSI Response for HIV and STIs in Madagascar project, PSI works closely with local partners and the Malagasy government to introduce community-based and client-centered approaches that simplify and adapt HIV services across the continuum of prevention, care and treatment. These approaches aim to both serve the needs of those most at risk from HIV and reduce the burden on an overstretched health system.
PSI is leading with consumer insights to create new opportunities for consumers to become active participants in their own healthcare.
PSI began scaling up community HIV screening services through peer educators. Over 200 trained and trusted community agents provide information, empathy, and discretion to empower at-risk individuals to participate in a simple 15-minute screening process. As a result, the HIV screening rate has dramatically increased, from 6,372 to today around 13,700 people screened per month. Reactive cases are typically accompanied to public and private health facilities for confirmation and rapid access to treatment. By moving these services out of the clinic, providers can prioritize the smaller number of suspected positive cases where their expertise is most needed.
The effectiveness of this approach is further enhanced by “index testing”, whereby exposed contacts (i.e., sexual partners, biological children and needle-sharing partners) of an HIV-positive individual (i.e., the “index client”), are actively researched and offered HIV testing services.
These small, low-cost sites are typically located around neighborhoods that are convenient for target groups. They offer safe and discrete spaces operated by peer educators offering a range of educational materials and health services, including HIV and sexually transmitted infection (STI) testing, family planning, lubricant gels and condoms, and, more recently, as a site for COVID-19 vaccination. Visiting public sector doctors also provide such services as confirmatory testing and antiretroviral drugs. Furthermore, each site also has a trained counselor to provide psychological support to HIV-infected individuals, their partners, families, and caregivers.
To improve sustainability, effort is being made to strengthen the technical and operational capacity of the three local partners who are in charge of providing service delivery in 46 distinct geographic locations across the country recognized as being at high risk—Action Socio-sanitaire Organisation Secours (ASOS) operating in the capital Antananarivo and the east of the island, Action pour la Justice et le Progrès des Populations (AJPP) working in the north and west, and the MAD’AIDS network that supports people living with HIV in areas around Antananarivo and in the south of the island.
In addition, with the support of the Ministry of Public Health, PSI also trained 12 private sector general practitioners from across the island to supplement the capacity of the public sector providers to conduct confirmation tests and provide antiretroviral drugs.
In exchange for maintaining medical records and regularly reporting aggregate data to the Ministry of Public Health, these private sector providers obtain access to public sector medications and test kits. This has the potential to open new avenues of community service delivery given vulnerable and marginalized groups’ preference for patronizing private providers for reasons of convenient opening hours, proximity, and friendlier service.
In 2021, the project introduced “e+zaho”, a digital platform offering integrated services for populations most at risk. The platform provides clear and detailed information on a range of relevant health topics, access to 24/7 online consultations, and referrals to peer educators.
Building on previous digital HIV awareness and referral tools aimed primarily at hidden populations, “e+zaho”incorporates messages on discrimination and stigma, gender-based violence, sexual and reproductive health, malaria, and COVID-19.
The result is over 5,000 registered users, 80% of whom represent most-at-risk populations aged between 18 and 35 years. It has led to more than 2,100 successful referrals to health facilities for STI cases and HIV testing, and other health services. Furthermore, all confidential information collected is linked to a unique client identification code to ensure patient anonymity.
Evidence from across different settings in sub-Saharan Africa have shown HIVST to be safe, acceptable, and effective to increase testing coverage and linkage to care by reaching those who may not otherwise test. Self-testing is being introduced in three locations in support of existing community-based approaches to help bring screening services to hard-to-reach groups—even for peer educators. Kits may be given to HIV-positive patients to share with their intimate partners, who may be too scared to come forward due to stigma.
In addition, the project is also piloting PrEP among 60 people in three drop-in centers across the island, with a particular focus on discordant couples and young men who have sex with other men, and who are typically among the most vulnerable groups for HIV. Once the acceptability of this approach has been demonstrated, the service will be scaled up to all drop-in centers and other sites across the island.
 Examining the effects of HIV self-testing compared to standard HIV testing services in the general population: A systematic review and meta-analysis, Jamil et al, eClinical Medicine, July 2021. https://doi.org/10.1016/j.eclinm.2021.100991