Social franchising of community‐based HIV testing and linkage to HIV care and treatment services: an evaluation of a pilot study in Tshwane, South Africa

• Published in: Journal of the International AIDS Society 2018-12, Vol.21 (12), p.e25216-n/a
• Main Authors: Shamu, Simukai, Farirai, Thato, Kuwanda, Locadiah, Slabbert, Jean, Guloba, Geoffrey, Johnson, Suzanne, Khupakonke, Sikhulile, Masihleho, Nomea, Kamera, Julius, Nkhwashu, Nkhensani
• Format: Article
• Language: English
• Subjects: Acquired immune deficiency syndrome; Adult; Aged; AIDS; AIDS Serodiagnosis - economics; Analysis; Automation; Care and treatment; Community Health Services; Counseling; Data collection; Diagnosis; Employees; Family planning; Female; Franchisees; Franchising; Health care industry; Health facilities; Health Personnel; HIV; HIV infection; HIV infections; HIV Infections - diagnosis; HIV Infections - drug therapy; HIV Infections - epidemiology; HIV positivity; HIV testing; HIV testing and linkage cost; HIV tests; Human immunodeficiency virus; Humans; linkage to care; Male; Mass Screening; Medical tests; Middle Aged; Objectives; Pilot Projects; Privatization; Quality control; Reproductive health; Risk factors; Small business; social franchising; South Africa; South Africa - epidemiology; Studies
• ISSN: 1758-2652; 1758-2652
• DOI: 10.1002/jia2.25216

Introduction Although HIV testing services (HTS) have been successfully task‐shifted to lay counsellors, no model has tested the franchising of HTS to lay counsellors as independent small‐scale business owners. This paper evaluates the effectiveness of a social franchisee (SF) HTS‐managed pilot project compared to the Foundation for Professional Development (FPD) employee‐managed HTS programme in testing and linking clients to care. Methods Unemployed, formally employed or own business individuals were engaged as franchisees, trained and supported to deliver HTS services under a common brand in high HIV‐prevalent communities in Tshwane district between 2016 and 2017. SFs were remunerated per‐HIV test and received larger payments per‐HIV‐positive client linked to care. In the standard HTS, FPD employed counsellors received similar training and observed similar standards as in the SF HTS, but were remunerated through the normal payroll. We assessed the proportion of clients tested, HIV positivity, linkage to care and per‐counsellor cost of HIV test and linkage to care in the two HTS groups. Results The SF HTS had 19 HIV counsellors while FPD HTS employed 20. A combined total of 84,556 clients were tested by SFs (50.5%: 95% confidence interval (CI) 50.2 to 50.8)) and FPD (49.5%: 49.2 to 49.8). SFs tested more females than FPD (54.1%: 53.6 to 54.6 vs. 48%: 47.7 to 48.7). SFs identified more first‐time testers than FPD (21.5%: 21.1 to 21.9 vs. 8.9%: 8.6 to 9.1). Overall, 8%: 7.9 to 8.2 tested positive with more clients testing positive in the SF (10.2%: 9.9 to 10.5) than FPD (5.9%: 5.6 to 6.1) group. The SFs identified more female HIV‐positive clients (11.1%: 10.7 to 11.6) than FPD (6.5%: 6.2 to 6.9). The SFs linked fewer clients to HIV care and treatment (60.0%: 58.5 to 61.5) than FPD (80.3%: 78.7 to 81.9%). It cost four times less to conduct an HIV test using SFs ($3.90 per SF HIV test) than FPD ($13.98) and five times less to link a client to care with SFs ($62.74) than FPD ($303.13). Conclusions SF HTS was effective in identifying more clients, first‐time HIV testers and more HIV‐positive people, but less effective in linking clients to care than FPD HTS. The SF HTS model was cheaper than the FPD‐employee model. We recommend strengthening SFs particularly their linkage to care activities.