South Africa has the highest number of people living with HIV and the largest HIV treatment program globally. Despite the expansion of HIV programs to ensure testing, treatment, and retention in care, a shortage of health workers with HIV expertise has made it difficult to ensure the full implementation of these programs.
In 2018, South Africa launched the Youth Health Africa (YHA) program, which places young adults as temporary lay health workers (LHWs) in non-clinical internships at health facilities. The YHA program provides interns with one-year placements as programmatic or administrative interns: programmatic interns serve as HIV testing counsellors, patient navigators, or tracers while administrative interns serve as data collectors. LHWs can undertake HIV testing and counseling responsibilities as part of YHA to increase HIV testing, treatment initiation, and patient retention. Moreover, YHA aims to empower youth by giving them the opportunity to gain hands-on work experience, which is hoped to increase employability and reduce unemployment among youth.
In a recent publication, Dr. Ann Duerr, a professor in the Public Health Sciences Division, and her team in collaboration with the Aurum Institute in Johannesburg evaluated the impact of the YHA program on HIV service delivery in two South African provinces (Gauteng and Northwest). This is an important question; according to Dr. Deanna Tollefson, a postdoctoral fellow in Dr. Duerr’s lab and leader of the study, “Prior to our research, although interns had proven beneficial in the business sector, it was uncertain how addition of untrained youth as interns would affect the health sector, specifically HIV service delivery. Perhaps it would be beneficial, but there was reason to believe it could have a neutral or even detrimental effect. Ultimately, what we found is the program appeared to positively impact HIV service delivery.”
To examine the impact of YHA on HIV service delivery, Dr. Duerr's team conducted interrupted time series analyses in which they used linear regression, taking into account facility-level clustering and time correlation, to compare trends in seven HIV service indicators related to HIV testing, treatment initiation, and retention in care before and after interns were placed.
“This research showcases how quasi-experimental designs can be used to examine complex public health interventions” said Dr. Tollefson. “Sometimes, policy makers implement public health practice interventions in ways that don’t allow for controlled trials or other prospective evaluations. However, using quasi-experimental designs like this can allow us to rigorously (and inexpensively) assess program impact in a retrospective fashion.” Importantly, their study relied solely on routinely collected data and thus had minimal costs while providing useful data for program implementers and policy makers.
Dr. Duerr’s team found increasing trends in the number of people tested for HIV, newly initiated on treatment, and retained in care in facilities following the introduction of YHA interns. Interestingly, this trend was significantly higher in facilities with more programmatic interns. However, there was no difference in trends in the number of patients newly diagnosed with HIV or the number initiating treatment within 14 days of diagnosis before or after interns were introduced. Overall, the researchers concluded that interns could potentially improve HIV service delivery in health care facilities by improving HIV testing, treatment initiation, and patient retention. The team’s results are especially significant because they position YHA as a potential solution to two important issues facing Sub-Saharan Africa: dire healthcare worker shortages and high youth unemployment.
Going forward, Dr. Duerr hopes the YHA team can examine “how this program could be adapted to areas of the health sector outside of HIV —such as cancer care or chronic disease care” as well as “how effective this program could be in addressing the long-term employability of young people and/or the healthcare worker shortage in Sub-Saharan Africa or other resource-limited settings.”
The spotlighted research was supported by the National Center for Advancing Translational Science (NCATS).
Fred Hutch/University of Washington/Seattle Children’s Cancer Consortium member Dr. Ann Duerr contributed to this work.
Tollefson D, Dasgupta S, Setswe G, Reeves S, Churchyard G, Charalambous S, Duerr A. Does a youth intern programme strengthen HIV service delivery in South Africa? An interrupted time-series analysis. J Int AIDS Soc. 2023 Apr;26(4):e26083. doi: 10.1002/jia2.26083. PMID: 37051619; PMCID: PMC10098286.