Realist evaluation of a community-based antiretroviral therapy programme for key populations in Nigeria

Key populations (KP: female sex workers, men who have sex with men, transgender people, and persons who inject drugs) are disproportionately affected by HIV/AIDS and are at increased risk of contracting HIV compared to the general population. They are underserved and have limited access to quality HIV prevention, care and treatment services. To optimize access to quality HIV services among KP and improve treatment outcomes (such as retention-in-care, medication adherence, and viral suppression), the World Health Organization recommended community-based approaches to HIV service delivery. However, to inform the successful roll out and scale-up of community-based ART service delivery models for KP (KP-CBART), there is a need to study long-term outcomes and to explain the dynamics between contextual factors and mechanisms that influence the outcomes for successful implementation. The overall aim of this PhD research work is to use the realist evaluation approach to evaluate the performance of KP-CBART models for KP in Nigeria and other sub-Saharan African countries. Findings from this evaluation will provide answers to the following questions: “what works?”, “how and why does it work?”, “for whom”, and “in what circumstances (context)”?. ART uptake, linkage to ART, retention in care, viral load coverage and viral load suppression are less good in KP-CBART than in the general population, and fall short of the UNAIDS 95-95-95 targets. This calls for further differentiation of KP-CBART to improve the outcomes of individual clients and programmes. Also, to achieve the UNAIDS 95-95-95 target, the policy context needs to change to remove access barriers such as criminalization policies against same-sex, drug-use, and sex trade. On the other hand, clinical outcomes in KP-CBART were at least as good as those in facility-based care. The thesis provides an empirically tested hypothesis (programme theory) that where HIV-positive KP receive ART in a safe place, KP clients will adhere to treatment and will be retained in care because they feel safe and trust the healthcare providers. Also, we show that the involvement of KPLHIV in the design, planning and implementation of HIV services improves medication adherence and retention in care because they perceive HIV services to be KP-friendly. Moreover, continuous psychological and social support enhances retention. In conclusion, this research shows that clinical outcomes in KP-CBART need to improve. Providing a safe space, participation, and social support are ways to strengthen utilization of care.