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How best to deliver HIV and complex disease care in rural settings?

By Rajesh Panjabi, MD, MPH | 13 Aug, 2008 Last edited by Robert Szypko on 02 Aug 2011

I help run a Liberia-based social justice organization, Tiyatien Health ("Justice in Health"), which, in partnership with the Liberian Ministry of Health, has built the first community-based HIV treatment program in rural Liberia. Inspired by Haiti's HIV Equity Initiative, our program, seeks to determine how best to deliver HIV and complex disease care in rural settings.

Liberia's HEI has had preliminary success employing CHWs to deliver ARVs along with socioeconomic support. You can find more information about our work at

A report at 6 months of implementation is available here:'s+HIV+Equity+Initiative+--+6+Months+Repo...



Mona Haidar, MD, MPH Moderator Replied at 10:12 PM, 26 Aug 2008

Dear Rajesh,

Thank you for sharing with the community the great work you and your colleagues are doing in Liberia!
Clearly your project values the role of community health workers and assesses and addresses the socioeconomic barriers that profoundly impact health.
I believe many of the patients you see are farmers or have farming skills.Are you considering to start agricultural projects or other income generating projects to ensure long term food security for the patients,their families and the community overall?
If you are interested to find out more about PIH model with regard to food and nutrition please check the link:
it discusses the following topics :food assistance to HIV and TB patients; infant feeding in the prevention of mother-to-child transmission (PMTCT) of HIV; pediatric malnutrition; school lunches; and agricultural initiatives.

All the best!

Emily Churchman Replied at 3:21 AM, 27 Aug 2008

Hello Rajesh,

It is a very interesting project and thanks for sharing the report. In northern Tanzania where we work (, there is pretty good HIV care and treatment at the district hospitals but a lot of positive people are living far away in rural areas. (Tanzania currently doesn't allow CHWs to distribute ARVs). We've had success with combining our CHW program with mobile care and treatment, where instead of bringing our clients into the hospital every month just to pick up their dose of ARVs, we bring some staff from the hospital with all the necessary drugs and supplies out to areas where there are 40-50 patients once a month. Of about 500 patients we have enrolled now, about 120 get ARVs this way; the rest get money to reach the hospital of their choice. It's cost effective for us and is a good way for CHWs to keep track of who is not showing up for their appointments. Wouldn't necessarily work everywhere, but is a good model for our communities.

All the best,


Etukoit Bernard Michael Replied at 6:05 AM, 1 Oct 2008

Thank you Rajesh for the great work, I work with the AIDS Support Organization (TASO) in Uganda. We started a community based ART program in 2004. Currently we have 20,000 clients on ART. I have a feeling of déjà vu that the challenges you face implementing your program are similar to the ones we faced over here. Our focus from the beginning was how to deliver free ART in the context of a continuum of care, achieve the best possible adherence for a clientele 90% rural based, impoverished with majority subsisting on peasant farming. The approach was three pronged; facility based services, robust community based services and establishing an effective link between the two service points.

The focus was to strengthen the community component of the program and establishing an endearing relationship between the facilities and the communities. The major thrust in the community was to integrate GIPA principles, identifying clients from a pool of those who are already on ART, are coping well and willing to work as volunteers. Such clients had to have other attributes such as good adherence and are behavioral change role models in their communities.

Clients who initiate ART are mapped and details of their addresses kept in a directory to facilitate follow up and check upfront possibilities of LTFU. Each client has an assigned field team consisting of a Field Officer and a Counselor. A selection process for community volunteers is conducted involving clients residing in a particular locality and a facility based care team to identify expert clients who will serve as Community ART support Agents (CASA). This process also involves identification of Community Drug Distribution Points where clients come on appointed days to receive their drug refills in locations within their communities. This helps address some of the adherence challenges related to inability to meet transport costs to pick refills from the facilities.

CASA receive basic training on information on ART, knowledge and skills in peer education and counseling skills. The trained CASA perform the following activities in their communities: monitoring adherence through pill counting and self reports, monitoring drug tolerance and reactions through identifying and checking for common symptoms and signs, monitoring use of the basic care kit, mobilizing clients for attendance of drug distribution points, sensitizing families about Home Based VCT, sensitizing and educating family members for adherence support, participating in activities at the drug distribution points, sharing information and experience with other Peers, reporting emergencies to TASO and making appropriate referrals and keeping records of their work and reporting to immediate supervisor

If you will need additional information, I can be contacted at:

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