To date, there has been extensive research conducted around the effects of community-based HIV services across the treatment cascade. Such research has found, with some consensus, that community and home-based care may increase rates of testing for HIV, and support sustained uptake of HIV treatment [6, 41,42,43,44,45]. In the first-year evaluation of the CIRKUITS program in Zambia, targeted testing in the community showed success in reaching men, with high positivity yield (18%) and high linkage rates to treatment (97%) [46]. Similarly, outreach to enhance the impact of “test and treat” for HIV were found to achieve high cascade coverage by the second year of follow-up in 16 communities in Kenya and Uganda, including for men and mobile populations [47]. Outreach components in these studies included community-based multi-disease prevention strategies, home-based testing, facilitated linkage to care, and tracking for individuals who were not linked to care [10, 47].
Our findings indicate that recent shifts in PEPFAR funding and strategy for HIV/AIDS programs in Kenya and Uganda, specifically the transitioning of certain facilities and jurisdictions to CS, resulted directly and indirectly in a loss of financial and technical support for outreach. Based on study findings, local health systems were unable to re-hire, replace or absorb informal staff or reinvigorate community-based programs that had been established with the support of PEPFAR, despite official expectations. According to our respondents, the loss of support for outreach had direct and immediate effects on the ability of facilities to provide certain services. Respondents of all types in both countries consistently indicated that CS facilities have experienced challenges in (i) conducting general education and awareness campaigns to their surrounding communities, (ii) providing testing outside of their facilities, including amongst target populations, (iii) tracing clients who default, (iv) providing clients with psychosocial support through expert clients, peer mentors, and mentor mothers, and (v) facilitating non-HIV related services within the community.
Our respondents’ concerns about how the loss of outreach may affect PLHIV and their communities over time links closely to existing data on the value of outreach services across the treatment cascade in support of reaching the 90–90-90 targets. In relation to the 1st 90, community-based testing, across modalities, has been shown to achieve high coverage and higher testing rates across KPs compared to facility-based testing [42]. Testing in the community has also been found to identify HIV-positive individuals earlier on in disease progression, allowing for earlier linkage to treatment. Although the shift by PEPFAR to classify community-based testing as a non-core activity is intended to better maximize resources by testing targeted populations rather than populations with very low prevalence, this potentially overlooks the benefit that can be achieved from conducting HIV testing in the broader population [42]. In addition, community-based education and awareness programs have been demonstrated to improve overall knowledge about HIV and its transmission, increasing the proportion of people who get tested and seek counselling [48]. The loss of outreach subsequently severs this initial first linkage between the health system and the community.
For the 2nd 90, loss of support in the form of expert clients, peer mentors, mentor mothers, and PLHIV support groups has implications for the ability of facilities to initiate and maintain clients on treatment. Psychosocial support through support groups and expert clients or peer mentors has been found to be a significant factor in treatment adherence across studies in SSA, including in Kenya, Swaziland, Lesotho, Namibia, Botswana, Uganda, Malawi, and Ethiopia [49,50,51,52]. In addition, the ability to physically trace clients in the community who have defaulted has been linked to better adherence outcomes, even amongst mobile and at-risk populations in unstable settings [51, 53]. Our study context in Kenya, where clients reside in remote and unstable regions of the Northeast, may be particularly susceptible to defaulting as a result of environmental factors, like drought and violence, and may be the most in need of additional support such as defaulter tracing.
Finally, for the 3rd 90, suppressing viral load is contingent on the ability of clients to maintain sustained treatment. In a multi-faceted community-based program implemented in Kenya and Uganda that included universal testing, linkage to care, treatment, and community-based follow-up, viral suppression increased by 35% over the 2-year intervention [47]. Authors attribute high rates of community engagement and retention partly to the delivery of non-HIV related services for diseases such as hypertension and diabetes, which may have increased the attendance of men. In addition, monitoring of viral load suppression is a critical component for managing treatment and treatment failure in clients; suggested strategies for higher risk populations include testing through mobile clinics at the community level [54, 55]. The loss of support for outreach may limit providers’ ability to monitor clients on a routine basis, in turn increasing risk for treatment failure, treatment resistance, transmission, and morbidity.
In losing support for outreach without adequate replacement by local/national governments or other donors, there is concern that a critical linkage into communities will be lost and exacerbated by existing stigma, changing migration patterns and ongoing health system decentralization. In Kenya, new infrastructure development brings concerns for increased migration and evolving patterns of disease transmission, in an ongoing setting of instability due to conflict and violence [26, 27]. In Uganda, some districts categorized as CS were established relatively recently, split from districts where HIV prevalence and burden are high (e.g. Luuka and Bulambuli), and poor governance and weak health systems may continue to pose a challenge. Similarly, in Kenya, devolution to the county system took place in 2013, only 3 years prior to when GP began. In both countries, the loss of support for outreach may be complicated by reduced monitoring in settings where the health system is weak, geographic barriers exist to reaching facilities, and in the case of Kenya, ongoing violence in the transitioned region complicates access. At the time that this study was conducted, neither country had yet to identify a strategy or plan to account for the loss of PEPFAR support to ensure the continuation of outreach, nor does it seem that the contextual issues and emerging trends in the HIV epidemic were considered for the decision to terminate support.
Lessons learned
There are a number of lessons that can be learned from the experiences documented in Kenya and Uganda for future funding transitions in HIV programming as well as other disease areas. Firstly, improved communication down to the sub-national and facility level may have provided opportunity for existing outreach programs to be better integrated into local budgets, or for alternative donors to be identified. In Kenya, it was found that although GP was well communicated at the national level, there was little to no communication down to the counties, resulting in abrupt cessation of services at the facility level [34]. In Uganda, while the majority of facilities were directly informed by IPs, on average they were provided with 3 months-notice, which was likely insufficient for facilities to identify feasible ways to maintain their outreach programs [56]. Secondly, in both countries, the overall timeline for GP was relatively short. GP planning first began in 2015, and was largely completed by late 2017. Furthermore, GP took place in both countries outside the normal budget cycle, limiting opportunities for restructuring of funding to cover outreach. The rapid pace at which this took place, coupled with limited communication and documentation, likely resulted in a missed opportunity for local actors and government to create a cohesive plan to step-in [56]. Thirdly, ongoing support for monitoring would be valuable for assessing changing needs over time as the local health system attempts to adapt. In Kenya, the IP stepped in for a period of 6 months to reinstitute support after monitoring data indicated that counties were not able to cope [34]. In Uganda, the frequency of respondents describing patients LTFU is concerning, and ongoing monitoring support may be able to detect shifts in HIV service provision. These lessons align with what Vogus and Graff describe as “six key steps for transition,” regarding the need for intensive stakeholder involvement over a prolonged period, and the importance of ongoing support for monitoring and evaluation to ensure minimal disruption of services [57].
More broadly, PEPFAR’s GP process reflects the need for development assistance partners to reflect critically on the outsized role they have played in shaping country responses to the HIV epidemic over the decades and to take this into consideration when planning transition efforts. Foreign aid and development assistance for health has heavily influenced health programming, and some argue that DAH has detracted from country level efforts to invest in building up robust health systems, instead prioritizing spending to align with donor objectives and short-term projects [58]. Donor funding for HIV, in many places, has created parallel health systems while siphoning off critical human resources to externally funded projects [59]. As seen in the findings presented, these gaps are subsequently exposed when long-term funding disappears, leaving fragile and poorly funded health systems to adapt under severe resource constraints. In the global context of decreasing funding, donors should consider that they have had a disproportionate amount of influence in shaping country health systems, and must take responsibility for ensuring that any reductions to funding are done so in a way that does not do further harm. This responsibility is particularly important with regards to avoiding potential harms for affected communities and individual patients who cannot engage in global dialogues on DAH.
There is a need for further research on how losing existing outreach impacts not only immediate health service delivery but also client physical and mental well-being, disease patterns, and epidemiology in the longer term, particularly for KPs and marginalized populations. Further study into how outreach services have or could rebound after transition are also needed to help with successful transition planning. Finally, research and experimentation to understand how integrated outreach efforts may be carried out across services, such as TB, maternal, neonatal, and child health, or other chronic diseases is critical to identifying ways in which such services can be maintained without the same levels of donor support. As global funding levels stagnate, such research is needed to ensure that countries can adequately achieve global targets for ending the HIV epidemic and achieving the UNAIDS 90–90-90 goal.
Limitations
This study presents a number of limitations. Firstly, outreach was not a key focus of the original evaluation but the loss of support and the attendant effects emerged as an important theme across data sources early on. Secondly, in both countries, other ongoing events at the national level took place during the study period, possibly affecting respondents’ views. In Kenya, two health worker strikes caused notable service disruption across the country during the study period making it difficult, at times, to reach relevant respondents. In Uganda, the process of rationalization whereby districts were transferred between PEPFAR agencies (e.g. USAID, the Centers for Disease Control and Prevention, and the Department of Defense) in an attempt to improve overall efficiency and avoid duplication took place simultaneously with GP. Respondents were often confused by the two processes due to their similarity, potentially affecting their recall. Thirdly, it is possible that respondents may have overstated the effects of losing outreach services in the hope that this would lead to a resumption of support, however interviewers introduced themselves in a manner which did not associate them with potentially influential stakeholders such as USG. Fourthly, while no respondents refused to speak during the facility level case studies, a number of invited FGD respondents did not come to the actual focus group. Key voices and experiences at the client level may therefore have been missed. Finally, this study took place in the period immediately following GP, with relatively short periods of time between rounds. It is possible that the effects of the GP had yet to be fully experienced, and additional follow-up research may elucidate longer term effects.