6 treatment and adherence, the conﬁdence in the care provider and the net eﬀectiveness of the treatment, and the self-con- ﬁdence to be able to manage challenges inherent to lifelong treatment. Group education, shared decision making and social support motivate and empower PLWHA who wish to become better self-managers [6]. Community participation, as described in Mozambique, responding to real needs and involving the communities straight from the start in the planning and the implementation will motivate and em- power those engaged and is a precondition for sustainability of activities embedded in the community [25]. To be successful, service delivery in SSA should be adap- ted to African personhood, grounded in social integrity and the need to maintain social support networks [14]. In our experience with the CAG in Mozambique, social relationship networks among CAG members in a context of economic hardship are used to overcome social, ﬁnancial, and practical diﬃculties. They are based on trust, cooperation, reciprocity, and sociability. They contain a silent agreement about being supported and supporting, knowing that these roles can change over time and what is invested will give a return [26]. CAG members in Mozambique have a mutual agreement to support each other on a daily basis. As a result, such social networks can be an important resource to reinforce self- management and adherence [22]. 4.2. Examples of Expert Patient Involvement in ART Provision in SSA. We looked at the literature for examples of involve- ment of PLWHA as expert patient in the ART provision in SSA and found only two published examples: one example of trained PLWHA in Kenya and another of self-formed peer groups in Mozambique. In both models, ART reﬁll is dissociated from clinic visits. Routine clinic visits are sched- uled three- or six-monthly, respectively, in Kenya and Mozambique. In between, patients can go to the clinic when- ever they are sick. Community ART provision improved the accessibility and aﬀordability of ART, as it decreased direct costs for transport and indirect costs due to time spent travelling and queuing in a health facility. Both programs had similar or improved treatment outcomes compared to conventional care and a reduced workload in the health facil- ities. Both programs ﬁt in the concept of the expert patient, as PLWHA were motivated to acquire self-management skills to manage their condition and to support fellow peers, using their day-to-day experience of living with HIV. The major diﬀerence between both programs is that the trained PLWHA in Kenya are remunerated, equipped, and considered as an extension of the health care system, whereas in Mozambique the CAG are more community owned [20–22]. A possible limitation of the literature review is publica- tion bias, selecting only ﬁeld experiences resulting in positive outcomes. In addition, many interesting experiences are local problem-solving strategies, which are never reported in the scientiﬁc literature. However, these pilot models conﬁrm results of recent reviews indicating that task-shifting to PLWHA as expert patients can be eﬀective under certain conditions and can increase signiﬁcantly the number of ser- vices provided and population reached at a given level of AIDS Research and Treatment quality and cost [27, 28]. There is a need to assess further the potential of care models based on voluntarism in Mozambique versus remunerated expert patients in Kenya in terms of eﬀectiveness, eﬃciency, and sustainability. For example the cost-eﬀectiveness of both strategies needs to be measured and compared. Additional staﬀ such as peer CHW in Kenya require additional means to pay them salaries and to train and equip them, whereas full responsibility of PLWHA for medical care functions as in Mozambique implies an inevitable loss of control for the provider. It is important to balance both the costs and the yield of each approach, in terms of impact on treatment outcomes and quantity of services provided for a given cost. 4.3. Possible Concerns. Often mentioned concerns related to community-embedded ART programs are stigma and fear for reduced quality of care. Stigma is a known barrier to adherence as it threatens social integrity and patients run the risk of becoming isolated. The impact of the visibility of HIV- related activities on stigma in the community needs further investigation. In Kenya peer CHW were named health coun- sellors to avoid the AIDS label [20]. On the other hand, when PLWHA support each other and form a social network, the negative impact of stigma can be overcome, as documented in Mozambique [29]. In South Africa it was found that bud- dies, support groups, and CHW predict and sustain treat- ment success [5]. Quality of care related to task shifting and other inno- vative models of service delivery is another concern raised. However, when considering survival as the most important indicator of quality of care, peer provision of ART will always compare favourably with no treatment as ART is the only eﬀective clinical intervention to reduce HIV-related mortality [30]. Community-based ART by lay workers in Uganda led to a 90% reduction of mortality among adults and a large reduction of mortality among their children in a population that otherwise would have had diﬃculties to access care [17]. However, involving PLWHA as expert patients in their own lifelong care is not a panacea. Models engaging commu- nities should not be shaped just to ﬁll the gaps in the health system or to strengthen it. Instead, they should be based on the needs of the PLWHA, thus requiring their involvement in the design and planning of the program [25]. There is a need to develop both the community and the clinical platform as complementary pillars of health systems [31]. 4.4. Future Prospects for HIV Self-Management. Once the concept of the expert patient is accepted and established, we think there are several further prospects that could be explored. First, once oral HIV tests will be available on African markets, there is a potential to expand testing in communities [32]. Second, the use of point-of-care testing could be further explored. For example, point-of-care CD4 techniques can be integrated in community delivered ser- vices, so that trained expert patients could assume medical tasks such as HIV testing, CD4 counts, and possibly deciding on ART initiation for uncomplicated patients [8]. Third,