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Recognizing and supporting health workers to advance and sustain HIV gains: lessons from PEPFAR programmes during the COVID-19 response

Hoover, Jerilyn R.a; Frymus, Diana E.a; Ifafore-Calfee, Temitayo A.b

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doi: 10.1097/QAD.0000000000003007
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The COVID-19 pandemic brought the need for a well equipped and supported health workforce to the forefront. Health workers have been recognized as critical to ensuring health system resiliency to maintain delivery of essential services and respond to emerging threats. Throughout the COVID-19 pandemic, health workers supported by the U.S. President's Emergency Plan for AIDS Relief (PEPFAR) have worked tirelessly in new and innovative ways to rapidly adapt HIV service delivery models under challenging circumstances to maintain essential service provision and support treatment continuity. In 2021, designated as The Year of the Health and Care Worker, we pause to recognize their contributions and reflect on lessons learned for building resilient health workers and health systems to support further achievement of HIV global goals and beyond [1].


Continuity of health services is critical for populations receiving lifelong treatment, such as people living with HIV (PLHIV). PEPFAR supports treatment for nearly 17.2 million PLHIV [2]. There is much we can learn about supporting the health workforce from PEPFAR's planning, strategy and collaboration. In response to COVID-19, PEPFAR issued guidance on how implementing partners should work with country governments to adapt its HIV programmes to continue service delivery while protecting health worker staff and clients [3]. Mitigating the impact of the pandemic on HIV services required a collaborative, lockstep approach. This guidance ensured a standard approach, guided by country realities on a global scale. Additive health worker staffing supported by PEPFAR quickly enabled reconfiguration of HIV service delivery models to put public health measures like physical distancing into practice [4]. Health workers shifted provision of services into communities to decongest facilities and employed approaches to deliver virtual or telehealth services where possible. This included using digital platforms such as mobile messaging services and social media to continue prevention and treatment activities. They accelerated multimonth dispensing of antiretroviral therapy (ART), supported decentralized drug distribution through private sector providers and home delivery of medications, and expanded use of HIV self-testing to decongest facilities [5,6]. In many countries, PEPFAR-supported health workers across facility and community settings further adapted by continuously repurposing staff to other duties from temporarily paused services to meet urgent needs. These adaptations offer lessons for building resilient country health systems and a health workforce equipped to withstand and respond to shocks and stressors, which is critical to also achieving sustained HIV epidemic control [7].

Use of human resources for health data

PEPFAR has placed priority on advancing health workforce data availability, including compiling inventories of staff being supported and developing tools to project staffing needs and guide allocation [7,8]. This available workforce data helped partners rapidly mobilize and reconfigure available staffing across countries. On a large scale, the ability to discover, monitor and share human resources for health data enabled models of staffing adaptations to be quickly shared and replicated across countries [9]. COVID-19 has underscored the importance of health workforce data and the need to have robust human resource information systems [10]. Real time up-to-date data are critical for workforce contingency planning and routine decision making required during a pandemic response. Despite progress made, data are still not readily available across countries and therefore an utmost priority for health worker resilience [11].

Ability to quickly reconfigure staff

During the onset of the pandemic, implementing partners worked with host-country governments to rapidly assess required staffing reconfiguration and skills needed for maintaining provision of HIV services as part of health worker contingency planning. Efforts were quickly organized to build skills and equip health workers (in many cases through virtual training) on COVID-19 screening and infection control measures to safely continue provision of HIV services. A summary of key shifts is listed in Table 1[12–21].

Table 1 - Adaptations to maintain provision of essential HIV services.
Theme Action/Adaptation
Reconfiguring staff Organized staff in rotating shifts to limit the numbers of staff in facilities at any time [12].
Increased use of home visits by health workers to decongest facilities [13]
Conducted risk profiling of health workers to identify those most at risk for complications of COVID-19 and shifted those staff to non patient-facing roles, like providing virtual support for clients, reviewing client files, packaging and arranging medication pickup with clients [14].
Used team-based approaches to increase task sharing to other healthcare workers so that specialists and nurses could be shifted to provide critical complex care services [13].
Some staff shifted with additional funding to focus on COVID-19 prevention, identification, and management [15]
Expanded access to self-testing for HIV in communities to reduce numbers of clients in health facilities [16]
Technology/Telehealth Staff supporting elective procedures like voluntary medical male circumcision (VMMC), which were paused in the early response shifted to online mobilization and client outreach or supported other activities [17]
Leveraged online platforms for outreach and patient tracking to message PLHIV with treatment information during the COVID-19 pandemic [18]
Telemedicine model introduced in some settings to deliver preexposure prophylaxis (PrEP) services almost entirely remotely [18]
Shifted to virtual case management for treatment support for PLHIV, including virtual support groups and health workers delivering medications to clients’ homes [18]
Health Worker Wellness Offering online mental health resilience course for health workers [19]
Wellness programmes to support staff with challenges like stress and financial difficulties during the COVID-19 pandemic [20]
Introduction of special COVID-19 related leave for health workers [20]
Mental health programme for staff to share their experiences and receive support [20]
Supportive audio messages for health workers to minimize stress [20]
Individual and group mental health counselling/sessions [21]

Models of HIV service delivery are ever evolving to further client-centred care, and COVID-19 has spurred more rapid adaptations and reconfiguration of staffing that have yielded benefits for clients and optimized the use of available workers. These changes, which in some cases have eased health worker constraints and workloads, are critical lessons for the long-term. Institutionalizing successful adaptations and building capacity to quickly enable future changes to optimize available health workers are key for resilience and sustained epidemic control.

Use of technology/telehealth

Across programmes, implementing partners supported extensive delivery of virtual and telehealth services by health workers to reach and engage clients. In South Africa, one programme helped social workers provide remote counselling and case management for vulnerable children, helping HIV-positive children continue treatment [18]. A project in Central America leveraged a mobile-phone based system to keep clients updated on where, when and how to get their ART [22]. Additional examples are listed in Table 1. Although further study is needed to understand client preferences and potential efficiency gains through virtual or telehealth services, use of remote and virtual services have expanded flexibility of service provision for health workers and clients. These benefits and the roles for technology in HIV service delivery should continue to be evaluated. Institutionalization would require that telehealth and virtual services are integrated into country government health systems and routine service delivery models and that health workers are trained to provide care effectively in a virtual manner [23].

Comprehensive support for health workers’ wellness

The COVID-19 pandemic has placed additional demands and stress on health workers and had harmful effects on their wellness and mental health [24,25]. Investment in health worker wellness has historically received less attention and investment. The pandemic has underscored the importance and many implementing partners have responded with new efforts to support the wellness and mental health of the health workers they employ to address stressors further exacerbated by working in a prolonged COVID-19 environment [21]. In South Africa, implementing partners have employed a variety of approaches, including provision of wellness and mental resilience training, organizing workshops and providing online psychosocial support services, and deploying mental health practitioners and social workers to provide in-house support services to staff [14]. See Table 1 for additional examples. WHO health worker guidance recommends interventions to ensure decent working conditions and mental health support for health workers, including preventing discrimination and violence against health workers, available and accessible mental health and psychosocial support services for health workers, promoting an environment wherein taking breaks, discussing challenges and seeking help are encouraged, and ensuring leaders know how to monitor the well being of their staff [10]. Although many implementing partners are initiating interventions to address health workers wellness during the COVID-19 response, the pandemic has further underscored the need to protect and support health workers, placing more human-centred focus on health workers as individuals, as essential preventive measures for ensuring resilience to respond to everyday stressors and emerging threats in the future.


Health workforce-led HIV service delivery modifications during the COVID-19 pandemic offer promising solutions to further advance and sustain HIV goals across countries and build resiliency for the future. Leveraging information on the types and locations of staff supported, health workers changed staffing models, shifting to provide services in innovative ways and moving staff to where most needed. Health workers delivered more virtual services and expanded the use of decentralized, multimonth dispensing of ART to ensure clients had enough medication to continue their treatment. Although many of these changes were enabled because of health workers supported by PEPFAR, they highlight key lessons for building resilient health systems and a health workforce that can withstand HIV service demands while responding to emerging threats. In a year dedicated to recognizing the contributions of health workers during the pandemic, we must ensure targeted and consistent support for the well-being of health workers who continue to risk themselves to deliver life-saving services.


All authors contributed to the idea for an earlier draft of the article, which J.H. had drafted and D.F. and T.I. reviewed and edited. J.H. and D.F. redesigned the article and revised subsequent drafts. T.I. reviewed and provided edits to the updated draft. All authors read and approved the final manuscript.

This article was made possible by the support of the American people through the United States Agency for International Development (USAID) under the U.S. President's Emergency Plan for AIDS Relief (PEPFAR).

Conflicts of interest

There are no conflicts of interest.

The views in this article are those of the authors and do not necessarily reflect the view of the U.S. President's Emergency Plan for AIDS Relief, the U.S. Agency for International Development or the U.S. Government.


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COVID-19; delivery of healthcare; global health; health workforce; HIV

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