Facing the Enemy
The term “SWAT Team” sparks images of highly trained police officers dealing with the most dangerous situations.
But the members of this SWAT team don’t have a background in law enforcement. Instead of tactical weapons, their ammunition is knowledge. And the enemy they’re fighting isn’t a bank robber, but a different sort of villain: the high rate of HIV infection in Kenya, where more than a third of the 1.5 million people infected are unaware of their HIV status.
The SWAT teams are the brainchild of AMPATH (The Academic Model Providing Access to Healthcare), a partnership between Moi University School of Medicine, Moi Teaching and Referral Hospital (both in Western Kenya), and a consortium of North American academic health centers led by Indiana University.
Since 2001, the Eldoret, Kenya-based group has been instrumental in addressing the nation’s HIV/AIDS crisis. As of 2016, the partnership has reached more than 1.5 million people, and increased the percentage of HIV-positive people in care (among those who know their status) from 93.8 percent in 2014 to 99.3 percent in 2016.
Their Perpetual Home-Based Counseling and Testing (PHCT) program – which includes the new SWAT teams— trains community health workers as HIV Testing Services Providers, capable of delivering door-to-door, in-home testing and counseling to high-prevalence communities.
“With a typical home-based testing program, you have a team of people that cover a large area of door-to-door counseling and testing, and once they get to everybody, they move on to the next catchment area,” says Megan J. Miller, associate director, Indiana University Center for Global Health and director of Development and Communications, AMPATH.
“That can be problematic, because people don’t always accept the diagnosis; they don’t necessarily go to the clinic or take care of themselves, so linkage and retention rates can suffer. With PHCT, we assigned counselors to a specific district to not only test, but stay in the area to help ensure they get the resources and treatment they need,” Miller says.
This slower, more holistic approach had many advantages, but logistically, it meant that one team could get to a household only once every three years. In high-prevalence areas, that three-year gap could mean new babies being conceived and born at risk of mother-to-child transmission, and people getting newly infected with the disease and becoming seriously ill without intervention.
“We don’t just focus on HIV, but rather the overall health of a family; the overall health of a community.” ”
When the Joint United Nations Programme on HIV/AIDS (UNAIDS) set for their ambitious 90-90-90 Goal this January – a proclamation aiming for 90 percent of all people around the world living with HIV knowing their HIV status, receiving antiviral therapy, and achieving viral suppression by 2020 – AMPATH knew they needed to speed things up.
“We realized that by focusing specifically on high-prevalence areas, we could place a larger cohort of counselors in a smaller population area, and get to households much quicker,” Miller says. “And although some of the team will move on to the next area, they always leave members behind to stay in each community, linking patients to clinics for treatment and making sure the needs of the community are addressed.”
With a plan in place and support from funders including the AbbVie Foundation, the AMPATH SWAT teams were born.
The SWAT team is comprised of 60 counselors, chosen from a select group of volunteer health workers from the community. “We meet with the village elders, county administration and leadership teams in our catchment areas, and they help identify people who are respected and trusted in the community to fill these roles,” says Shamim M. Ali, M.D., a physician advisor who works in-country with the SWAT teams.
Once the counselors are chosen, they go through a rigorous training program taught by AMPATH staff, led by public health specialist Dr. Samson Ndege. The training includes how to administer rapid HIV tests and provide counseling on HIV prevention and treatment. Upon successful completion of training, the counselors are assigned to an area and have a counselor supervisor who assists them with any issues they run into.
Counselors are also trained to use handheld electronic devices that allow them to collect data for analysis and support linkage to care. AMPATH’s electronic medical record system now holds the largest clinical data repository in Africa, and is active in more than 40 countries worldwide.
Before the SWAT teams swoop into a new area, AMPATH works with community leaders to arrange village meetings or special events to raise awareness about the counselors’ arrival. They make sure to stress that the home visits aren’t just about HIV – the counselors also screen for tuberculosis and malaria, assess immunization status and deworming of children, talk to pregnant women about attending antenatal groups, and more – which reduces stigma and makes the community welcome the knock on the door, not fear it.
“We don’t just focus on HIV, but rather the overall health of a family; the overall health of a community,” Ali says.
Three to four counselors are assigned to a particular village. First thing every morning, the team meets to decide which households within the high-prevalence area to target; each counselor is responsible for four households per day. At each of these households, the SWAT team counselor will offer home testing services, and collect necessary data. They might also swing by previously-visited households to make sure those who have tested positive for HIV have been successfully linked to care.
The SWAT team is embedded in the community, which allows them to adapt to specific needs or challenges – an agility that is central to AMPATH’s mission. “When we started nine or 10 years ago, the door-to-door testing model was something very new,” Miller says. “We’ve changed our approach throughout the years, being really innovative and also accepting when things aren’t going well and readjusting.”
In the evening, the SWAT team comes together once again to evaluate the work they’ve accomplished, and prepare for the next day. Within a month or two, they will have completed the targeted testing. Some will move on to the next area, and others will remain behind. This way, if someone fails to show up for a clinic appointment, a counselor can swing by to find out why.
It is these personal interactions that have led to AMPATH’s 98.8 percent rate of acceptance in SWAT team catchment areas. That’s a figure that makes the ambitious UNAIDS goals seem within reach, and gives hope of beating the bad guy – just like the other kind of SWAT team.