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The HIV Equity Initiative: Pioneering Comprehensive, Community-Based Care

In March 2007, Tiyatien Health, in partnership with the Liberian Ministry of Health and the National AIDS Control Program, launched the HIV Equity Initiative (HEI) – Liberia’s first comprehensive, community-based HIV treatment program – at the Martha Tubman Memorial Hospital (MTMH) in Zwedru, Grand Gedeh County. Before project initiation, patient’s narratives told of inaccessible medicines, long, costly trips to clinics, frequent food shortages, and a lack of family and community support for their illness. No patients in southeastern Liberia received anti-retroviral therapy (ART) and testing services functioned poorly despite HIV prevalence estimates as high as 13%.

Program Objective:

To develop an equitable model for the prevention and treatment of HIV/AIDS within the public sector that can be integrated to prevent and treat other chronic illnesses. Through this program, the National AIDS Control Program and the Ministry of Health will have the data necessary to seek funding for the establishment of a national program for the comprehensive, integrated care of HIV/AIDS and other chronic diseases.

Program Description:

Besides providing free services, the HEI incorporates three innovative components to improve ART delivery: training non-physician clinicians to prescribe ART; providing socioeconomic assistance through food packages and transportation stipends; and employing community health workers (“accompaniers”) to provide supervised antiretroviral therapy and psychosocial support.

At the health facility level, HEI’s strategy is based on the “four pillars” model developed by Partners in Health (http://model.pih.org/HIVmanual/chapter2/section2). The “four pillars” model involves providing comprehensive HIV services, including antiretroviral treatment (ART); treating and controlling tuberculosis; preventing and treating sexually transmitted infections; and providing PMTCT with reproductive health services, all in the context of a primary healthcare system.

The HEI’s integrated, clinical approach to HIV services is supported by a robust backbone of community health workers (“accompaniers”) who provide home-based health and socioeconomic services. In 2008, TH’s over 50 accompaniers conducted over 10,000 home visits to people affected by tuberculosis, HIV and chronic diseases and their communities to provide directly observed treatment and health talks, expanding their efforts to include prevention activities, awareness campaigns, and referrals. These invaluable accompaniers have referred over 2000 sick individuals from rural communities for early care seeking and primary healthcare services during prevention and awareness activities that reached over 30,000 people from rural communities.

In addition to providing comprehensive health services, Tiyatien Health addresses the socioeconomic needs of patients and their families by providing over 200 monthly economic stipends, food packages, and individual and group counseling sessions. Agricultural and small business trainings have recently been completed to help break cycles of disease, poverty and gender inequality plaguing our patients lives. These patients were provided agricultural kits and small business grants, helping families rebuild their lives after years of war, displacement, and little to no health care.

Since March 2007, more than 300 patients have been enrolled into care, and preliminary data shows a reduction in mortality AIDS patients on community-based ART. 

Program Impact:

Read more about the impact of our HIV/AIDS programs by clicking here.

• November 2006 – Foundation for Tiyatien Health’s work on rural healthcare and HIV/AIDS is laid when impoverished rural Liberian women infected with HIV work with TH staff to design a comprehensive HIV care program, ultimately the HIV Equity Initiative, focused on poverty reduction and inequalities. The life narratives of these rural Liberian women affected by AIDS are shared with the President of Liberia, Honorable Ellen Johnson-Sirleaf, and her Minister of Health, Honorable Dr. Walter Gwenigale.

• March 2007 – Tiyatien Health and Ministry of Health launch HIV Equity Initiative and begin Grand Gedeh County’s first HIV patient on antiretroviral treatment. Within two years, more than 300 patients will be in care—the largest rural HIV treatment program in Liberia.

• November 2007 – Tiyatien Health and the Liberian National AIDS & STI Control Program release its first official report on Liberia's HIV Equity Initiative, documenting dramatic impact on AIDS mortality and treatment retention at 6 months of implementation.

• January 2008 – Massachusetts General Hospital and Harvard University's Center for AIDS Research invites Tiyatien's HIV Equity Initiative to join its HIV Online Provider Education (HOPE) network. Tiyatien is one of very few rural clinics which has been invited into the HOPE network.

• March 2008 – Tiyatien receives over $100,000 in funding and in-kind support from the UNHCR and OFID to finance its HIV Equity Initiative.

• July 2008 – Tiyatien welcomes its new medical director, Dr. David Okiror, formerly with the Clinton Foundation HIV/AIDS Initiative in Liberia. In addition to providing HIV care, Dr. Okiror is one of only two physicians providing obstetric, pediatric and medical care to Grand Gedeh’s catchment area of over 100,000 people.

• August 2008 – In an abstract joined by the Liberian Minister of Health, Dr. Walter Gwenigale, Tiyatien Health and the Liberian Ministry of Health and Social Welfare present findings of the HIV Equity Initiative at the XVII International AIDS Conference in Mexico City.

• August 2008 - Liberian Ministry of Health partners with Tiyatien to launch first rural Chronic Care Clinic to integrate and strengthen HIV/TB and primary healthcare in Zwedru, Liberia. This is the only rural center targeting chronic conditions—including asthma, hypertension, diabetes, and congestive heart failure—in Liberia.

Representative Publications

• Panjabi R., Aderibigbe O., & Quitoe W. Towards universal outcomes: a community-based approach to improve HIV care in post-confl ict Liberia. XVII International AIDS Conference, Mexico City, Mexico; Aug 3–8, 2008:CDB030 (abstr).
• Panjabi R, Aderibigbe O, Quitoe W, et al. A Community-Based Approach to HIV Care in Rural Liberia: Liberia’s HIV Equity Initiative. National AIDS & STI Control Program. 2007 Nov. Ministry of Health & Social Welfare: Monrovia.
• Panjabi R. (2007) HIV Prevention and Care. In International Donor Community Report Card:
• Investment in Liberia’s Future. Institute for Policy Studies & Jubilee USA: Washington, D.C. pp. 7-9.

Read more about Tiyatien Health's HIV/AIDS presentations and publications.

Project Contacts:

• Valentine Sawyer, MD // Liberia Medical Director // vsawyerr@tiyatienhealth.org
• Kerry Dierberg, MD, MPH // Medical Director // kdierberg@tiyatienhealth.org
• Lindsay Kim, MD, MPH // HIV Program Analyst // lkim1@bidmc.harvard.edu

Project Deliverables:

• Reduction in mortality among HIV patients receiving community-based services
• Trained community health workers
• Extension of HIV testing and treatment
• Improved health infrastructure in southeastern Liberia
• HIV+ patients started on pre-ART and ART
• Improved socioeconomic status
• Reduced stigma associated with HIV/AIDS
• Programs successes and challenges