The Teach-Test-Link-Trace strategy

The UNAIDS and partners, proposed three new and ambitious targets called the UNAIDS 90-90-90 treatment targets that aimed to improve the entire HIV care continuum in 2020. Although all countries subscribed to this, only few countries have achieved all targets. Therefore, community-based interventions that involve people with HIV themselves (e.g. peer educators) in the entire HIV cascade and treatment are mandatory. Peer educators are HIV positive people who disclose their HIV status publicly and employed to counsel other HIV patients in health facilities. There is, however, a lack of evidence on the impact of peer educators in improving the whole HIV care and treatment cascade: HIV counselling and testing, treatment linkage, and virological suppression.

In this project, we will assess the impact of a peer educators led HIV testing, treatment linkage and follow up of patients, an intervention called teach-test-link-trace (TTLT) model. The title of the project is Teach-Test-Link-Trace model for the UNAIDS 90-90-90 treatment targets in Tigrai, Ethiopia: A cluster randomized trial. The teach-test-link-trace (TTLT) model is a new program in which peer educators counsel about HIV (teach), perform HIV testing (test) through pinprick house-to-house HIV testing (H2H) or OralQuick HIV self-testing (HIVST), link HIV positive patients to HIV care (link) and trace lost patients house-to-house (trace).

Project Phases

The project will employ a cluster randomized trial in 40 districts in Tigray, Northern Ethiopia in five phases over five years.

Phase 1 assesses the acceptability of the TTLT model using a cross-sectional survey.

 Phase 2 assesses the effectiveness of the model through comparing intervention and control groups. The intervention groups will receive one of the three home-based interventions provided by peer educators: (i) demonstrate and distribute OralQuick HIV self-testing kits (HIVST), (ii) perform pinprick HIV testing (H2H), and (iii) offer HIVST or H2H. The peer educators will refer all individuals of the three intervention arms to nearby health facilities for confirmatory test if the test result is positive. Peer educators also follow those who diagnosed with HIV through HIVST or H2H to link to HIV care and at 0, 3 and 6 months after antiretroviral therapy as part of the intervention. The control group will receive the standard of care in which nurses counsel and refer eligible household members to nearby health facilities to existing HIV testing services. The primary outcomes of the interventions are knowledge of HIV status (first 90), linkage to HIV care and treatment (second 90) and virological suppression (third 90). The secondary outcomes include health related quality of life, HIV related stigma and treatment adherence.

Phase 3 aims at process evaluation of the trial through qualitative interviews.

Phase 4 measures economic evaluation through cost-effectiveness analysis.

Phase 5 employs sustainability exit using nominal group technique analyses.