Raising the Bars: Designing, Implementing and Monitoring HIV Retention in Care Interventions

By Lucy Slater November 4, 2014

NASTAD’s Global Program builds the organizational, programmatic and human resource capacity of partner public health programs around the world. In this series of blog posts, we provide a snapshot of how we are supporting locally designed strategies to improve outcomes in the countries where we work. The previous posts describing how we are “Raising the Bars” can be found below:

Part VI: Designing, Implementing and Monitoring Retention in HIV Care Interventions

Central to both Treatment as Prevention and the HIV Care Continuum is retention in care. Barriers to treatment adherence and retention, such as high cost, transportation issues, and social isolation are often exacerbated in resource-poor settings, and consistently prove a challenge for ministries of health.

South Africa

I ACT Training March 2014 A group of I ACT Facilitators recently trained by NASTAD in Gariep Dam, Free State Province, South Africa.


NASTAD is working to improve linkage to and retention in HIV care in South Africa, where an estimated 5.6 million people are living with HIV and AIDS, the greatest number of people in any country worldwide. In 2009, the South African government initiated the Integrated Access to Care and Treatment (I ACT) Program as one important component of its national response to the HIV epidemic. I ACT targets people recently diagnosed with HIV and recruits them into community and health facility based pre-antiretroviral therapy (ART) care and support programs. These support programs provide critical information about HIV, healthy living strategies, and treatment and care options, and help to reduce the high rate of loss to the HIV care system. NASTAD South Africa has since worked in partnership with Provincial Departments of Health (PDoH) to support the integration of I ACT into the existing health system. Leveraging this experience, NASTAD is now supporting the government at the national level as it develops a National Strategy for Linkage to Care, Retention to Care, and Adherence to Treatment of Chronic Disease.


In Ethiopia, the government has made a strong commitment to provision of ART, with 249,174 adults and 16,000 children receiving ART as of 2012. However, among those enrolling in HIV care, approximately 25% were no longer retained in care after one year. Ethiopian regional health bureaus requested that NASTAD Ethiopia support them in designing effective community based interventions to help prevent this loss to care. After conducting a baseline assessment, which revealed a number of barriers and challenges for HIV patients to access medical care, NASTAD collaborated with local stakeholders to develop an intervention targeting HIV-positive adults in the rural town of Arba Minch.

In Arba Minch, 13 community support workers (most of whom were also living with HIV) were recruited and trained to provide:

  • Education on HIV treatment and healthy living
  • Counseling and social support (including helping clients to address feelings of internalized stigma, and barriers to adherence and retention in care)
  • Referrals to other community organizations for food or other assistance

The intervention was found to be highly successful, with very little loss to follow-up. Both the patients and the community support workers who participated in the program benefited greatly from the sense of mutual support, openness and positivity that this community oriented intervention provided.


In Haiti, patient attrition is a persistent issue, particularly among people co-infected with HIV and tuberculosis (TB). In Haiti today, an estimated 150,000 people are living with HIV, corresponding to 2.1% of the adult population. Compounding the burden of HIV is an aggressive TB epidemic: it is estimated that 30,000 people are living with TB in Haiti, and an estimated 20% of those TB patients are known to be HIV positive. The co-epidemic of HIV/TB complicates the Ministry of Health’s efforts to improve the health of the population and effectively leverage the Treatment as Prevention strategy.

NASTAD Haiti is supporting the Haiti Ministry of Health to optimize its existing Community Health Team program, which organizes teams of health workers to follow-up with people living with HIV and HIV/TB in their communities, ensure that they are linked to care, and understand and adhere to their treatment plans. NASTAD Haiti is building the Community Health Teams’ capacity to address the high attrition rates through mentored implementation of a toolkit that:

  • Ensures consistent, timely and quality care and follow up;
  • Identifies and supports patients who are at risk of loss to follow-up; and
  • Provides monitoring and evaluation data about the teams’ activities and outcomes.

This approach will strengthen local capacity to improve retention to care at the community level and increase community literacy with respect to HIV treatment, ultimately improving patient outcomes and achieving greater prevention benefits of HIV treatment.

If you are interested in learning more about how NASTAD Global works to strengthen the HIV Care Continuum in all of the countries where we work, please contact Lucy Slater.

Visit NASTAD.org/global to learn more about the NASTAD Global Program.

Gen Meredith, Associate Director, Global Program, NASTAD, Mark Griswold, Senior Manager, Global Program, NASTAD and Anna Carroll, Senior Associate, Global Program, NASTAD, also contributed to the development of this post.