Optimizing community linkage to care and antiretroviral therapy Initiation: Lessons from the Nigeria HIV/AIDS Indicator and Impact Survey (NAIIS) and their adaptation in Nigeria ART Surge
Authors: Jahun Ibrahim , Said Ishaq , El-Imam Ibrahim , Ehoche Akipu , Dalhatu Ibrahim , Yakubu Aminu , Greby Stacie , Bronson Megan , Brown Kristin , Bamidele Moyosola , Boyd Andrew T. , Bachanas Pamela , Dirlikov Emilio , Agbakwuru Chinedu , Abutu Andrew , Williams-Sherlock Michelle , Onotu Denis , Odafe Solomon , Williams Daniel B. , Bassey Orji , Ogbanufe Obinna , Onyenuobi Chibuzor , Adeola Ayo , Meribe Chidozie , Efuntoye Timothy , Fagbamigbe Omodele J. , Fagbemi Ayodele , Ene Uzoma , Nguhemen Tingir , Mgbakor Ifunanya , Alagi Matthias , Asaolu Olugbenga , Oladipo Ademola , Amafah Joy , Nzelu Charles , Dakum Patrick , Mensah Charles , Aliyu Ahmad , Okonkwo Prosper , Oyeledun Bolanle , Oko John , Ikpeazu Akudo , Gambo Aliyu , Charurat Manhattan , Ellerbrock Tedd , Aliyu Sani , Swaminathan Mahesh 
Published: September 2021

Background
Ineffective linkage to care (LTC) is a known challenge for community HIV testing. To overcome this challenge, a robust linkage to care strategy was adopted by the 2018 Nigeria HIV/AIDS Indicator and Impact Survey (NAIIS). The NAIIS linkage to care strategy was further adapted to improve Nigeria’s programmatic efforts to achieve the 1st 90 as part of the Nigeria Antiretroviral Therapy (ART) Surge initiative, which also included targeted community testing. In this paper we provide an overview of the NAIIS LTC strategy and describe the impact of this strategy on both the NAIIS and the Surge initiatives.

Methods
The NAIIS collaborated with community-based organizations (CBOs) and deployed mobile health (mHealth) technology with real-time dashboards to manage and optimize community LTC for people living with HIV (PLHIV) diagnosed during the survey. In NAIIS, CBOs’ role was to facilitate linkage of identified PLHIV in community to facility of their choice. For the ART Surge, we modified the NAIIS LTC strategy by empowering both CBOs and mobile community teams as responsible for not only active LTC but also for community testing, ART initiation, and retention in care.

Results
Of the 2,739 PLHIV 15 years and above identified in NAIIS, 1,975 (72.1%) were either unaware of their HIV-positive status (N = 1890) or were aware of their HIV-positive status but not receiving treatment (N = 85). Of these, 1,342 (67.9%) were linked to care, of which 952 (70.9%) were initiated on ART. Among 1,890 newly diagnosed PLHIV, 1,278 (67.6%) were linked to care, 33.7% self-linked and 66.3% were linked by CBOs. Among 85 known PLHIV not on treatment, 64 (75.3%) were linked; 32.8% self-linked and 67.2% were linked by a CBO. In the ART Surge, LTC and treatment initiation rates were 98% and 100%, respectively. Three-month retention for monthly treatment initiation cohorts improved from 76% to 90% over 6 months.

Conclusions
Active LTC strategies by local CBOs and mobile community teams improved LTC and ART initiation in the ART Surge initiative. The use of mHealth technology resulted in timely and accurate documentation of results in NAIIS. By deploying mHealth in addition to active LTC, CBOs and mobile community teams could effectively scale up ART with real-time documentation of client-level outcomes.