Research Article: Reaching the unreached: Performance of an enhanced peer outreach approach to identify new HIV cases among female sex workers and men who have sex with men in HIV programs in West and Central Africa

Date Published: April 3, 2019

Publisher: Public Library of Science

Author(s): Tiffany A. Lillie, Navindra E. Persaud, Meghan C. DiCarlo, Dismas Gashobotse, Didier R. Kamali, Magda Cheron, Lirica Nishimoto, Christopher Akolo, Hally R. Mahler, Maria C. Au, R. Cameron Wolf, Susan Marie Graham.


Finding new HIV-positive cases remains a priority to achieve the UNAIDS goals. An enhanced peer outreach approach (EPOA) was implemented to expand the delivery of HIV services to female sex workers (FSWs) and men who have sex with men (MSM) in three countries in West and Central Africa. The aim of EPOA is to identify new HIV-positive cases. EPOA was implemented in Burundi among FSWs, and in Cote d’Ivoire and Democratic Republic of the Congo (DRC) among both FSWs and MSM. Implementation ranged from five to nine weeks and was nested within a three-month reporting period. Standard outreach was suspended for the duration of EPOA implementation but was resumed thereafter. Summary service statistics were used to compare HIV seropositivity during standard outreach and EPOA. Trends were analyzed during the quarter in which EPOA was implemented, and these were compared with the two preceding quarters. Differences in proportions of HIV seropositivity were tested using Pearson’s chi-square test; p-values of less than 0.05 were considered statistically significant. Overall, EPOA resulted in a higher proportion of new HIV-positive cases being found, both within and between quarters. In Burundi, HIV seropositivity among FSWs was significantly higher during EPOA than during standard outreach (10.8% vs. 4.1%, p<0.001). In Cote d’Ivoire, HIV seropositivity was significantly higher during EPOA among both populations (FSWs: 5.6% vs. 1.81%, p<0.01; MSM: 15.4% vs. 5.9%; p<0.01). In DRC, HIV seropositivity was significantly higher during EPOA among MSM (6.9% vs. 1.6%; p<0.001), but not among FSWs (5.2% vs. 4.3%; p = 0.08). Trends in HIV seropositivity during routine outreach for both populations were constant during three successive quarters but increased with the introduction of EPOA. EPOA is a public health approach with great potential for reaching new populations and ensuring that they are aware of their HIV status.

Partial Text

Achieving ambitious global 95-95-95 targets for HIV testing, treatment, and viral suppression requires that HIV programs find new ways to identify HIV-positive individuals and initiate them on treatment [1]. Many programs for key populations (KPs) struggle to engage people not already reached through existing program services. Existing peer outreach and community-based programs may maintain a cycle of reaching the same individuals repeatedly while not reaching others who are less visible or outside known networks.

In Burundi, Cote d’Ivoire, and DRC, EPOA was implemented by existing community-based organizations (CBOs) with established outreach programs that delivered services to KPs in a variety of hot spots (i.e., geographic areas where KP individuals are present and where high HIV risk behaviors sometimes take place), such as karaoke bars, short-term guest houses, massage parlors, and truck stops. The existing CBO outreach services identified, hired, trained, and paid outreach workers. The outreach workers hired by CBOs were recruited from identified hot spots, and selection characteristics included willingness to work on an HIV project, good communication and leadership skills, ability to motivate peers to seek health services, and having a medium to large social network.

In Burundi, 2,451 coupons were distributed to FSWs, and 929 FSWs were newly recruited and tested for HIV through EPOA. Of those tested, 100 (10.8%) were newly diagnosed with HIV. In standard outreach within the same quarter, 5,164 FSWs were tested, and 211 (4.1%) were newly diagnosed with HIV. HIV seropositivity among FSWs was significantly higher through EPOA than through standard outreach within the quarter (10.8% vs. 4.1%, p<0.001) (Table 2). These results demonstrate that during a time-bound campaign, EPOA may be more successful than standard outreach for recruiting and testing KP individuals who have a greater likelihood of HIV seropositivity. Prior to EPOA, HIV seropositivity in all three country programs remained steady. The introduction of EPOA led to increased detection of new HIV-positive KP individuals who would not have been engaged otherwise. Reaching new HIV-positive individuals is a critical component of KP programs as they strive to achieve and contribute to epidemic control. The results presented here demonstrate EPOA’s public health potential in settings such as West and Central Africa. EPOA is a promising example of how a peer-to-peer, network-based, time-bound intervention can penetrate hidden and untapped KP members and connect them to HIV services.   Source:


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