Global Point of Care

Strengthening Referrals and Linkages in Swaziland

Strengthening Referrals and Linkages in Swaziland

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In Swaziland, where one in four adults is HIV positive and testing services are made available in a variety of locations, linking people who have been diagnosed with the virus to treatment in a timely manner is essential. HIV treatment not only reduces morbidity and mortality for people living with HIV (PLHIV), but also prevents new HIV infections because people who take their medications regularly are 90% less likely to transmit the virus to their sexual partners than PLHIV not on treatment.

However, global evidence suggests that as many as 70% of newly diagnosed HIV positive individuals never initiate anti-retroviral therapy (ART). With help from Alere, PSI’s Swaziland office - one of more than 50 around the world – is working to solve this problem.


In 2015, PSI realized we needed better approaches to support effective referrals and linkages for our clients testing positive for HIV. We reached out to our partner, Alere, for help. Through the Alere Fellows program, Dan De La Vega and Leanne Shearman dedicated three months of their time to analyze PSI’s work on linkages and referrals and make recommendations for improvement, using the work in Swaziland as a test case.

Global evidence suggests that as many as 70% of newly diagnosed HIV positive individuals never initiate anti-retroviral therapy (ART).

The result was a suite of tools and guidance documents that support both more standardized procedures and better use of data to focus resources. These include training for providers on motivational interviewing techniques to make post-test counseling sessions more effective, revised and improved standard operating procedures for HIV counselors and test sites, and cost and risk analysis for loss-to-follow-up.

With these new tools, PSI Swaziland revamped its approach to linking new positive clients with ART. They rolled out Dan and Leanne’s recommendations and added a few additional elements: they added “expert clients” – people living with HIV who are successfully taking ART and trained as peer supporters – to each of their HIV testing teams. Additionally, they offered client’s transport to their first clinic visits using outreach vehicles, which helped overcome a major barrier for many newly diagnosed PLHIV. As before, staff made follow-up telephone calls to ensure these clients were successfully enrolled into care.

As a result, the proportion of HIV positives successfully linked to care increased among female testers, from 69% to 85%, and among male testers, from 59% to 75%, between 2015 and 2016. These improvements translate directly into lives saved and infections prevented. Through its partnership with Alere, PSI Swaziland has accelerated the HIV response in one of the countries hardest hit by the epidemic.

But that’s not all. At PSI, we place tremendous value on our network and its ability to share information across the globe. We prioritize applying local knowledge to a larger global context and leveraging our learnings to maximize impact. We are sharing the tools and insights gained from our Alere Fellows widely across PSI’s technical and regional teams, so that they can apply and adapt them for use all over the world, amplifying the impact of this partnership and saving more lives.