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Improving Referrals for HIV Care Through Organizational Network Analysis

Thomas, James C., PhD, MPH; Agala, Bernard, PhD; Xiong, Khou, MPH; Powell, Richard, MA, MSc

Journal of Public Health Management and Practice: May/June 2019 - Volume 25 - Issue 3 - p E36–E44
doi: 10.1097/PHH.0000000000000839
Research Reports: Research Full Report

Context: The link between testing for HIV and obtaining antiretroviral therapy (ART) is central to the HIV/AIDS control strategies of UNAIDS (the “90-90-90” goals) and the International Association of Providers of AIDS Care (“Test and Start”). To ensure that 90% of those diagnosed with HIV/AIDS begin ART and 90% of those on ART achieve viral suppression, service providers not providing all services need to refer patients to other organizations.

Setting: Homa Bay, Kenya.

Objective: Homa Bay county's HIV/AIDS prevalence is one of the country's highest. We identified the organizations providing some aspect of HIV/AIDS care and investigated ways in which they work together, or do not, to cover the comprehensive needs of those they serve.

Design and Participants: We identified 56 organizations and interviewed a representative from each about his or her organization's services and its connections with the other 55, with particular interest in referrals from sites that test for HIV but do not treat infections to sites that do treat infections.

Main Outcome Measure: Referral connections.

Results: Referral connections among the 56 in the past 30 days were relatively rare, averaging fewer than 2; 13 organizations made no referrals at all. Notably, 5 facilities that test for HIV did not refer their clients to an ART provider. We found 2 distinct clusters of connected organizations: one in Homa Bay Township and the other in Rangwe subcounty. When we convened the organizations and presented our results to them, they expressed interest in establishing better connections and referrals.

Conclusions: Homa Bay has an opportunity to improve care for people with HIV/AIDS, in particular ensuring that those testing positive receive treatment, simply by making better use of the services already available. This can be achieved by informing each organization of the services provided by each of the others and by bringing the organizations together to plan and monitor the services' coordination. These steps could be implemented separately in each of the 2 organizational clusters.

MEASURE Evaluation, Carolina Population Center (Drs Thomas and Agala and Ms Xiong), and Department of Epidemiology, Gillings School of Global Public Health (Dr Thomas), University of North Carolina, Chapel Hill, North Carolina; and MEASURE Evaluation PIMA Project, Nairobi, Kenya (Mr Powell).

Correspondence: James C. Thomas, PhD, MPH, Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, CB #7435, Chapel Hill, NC 27599 (

For their assistance with the study, the authors thank the study participants in Homa Bay; Vincent Waringa, the Homa Bay County Deputy Director of Health; the staff of the MEASURE Evaluation PIMA Project in Kenya; and the MEASURE Evaluation project staff in Chapel Hill, North Carolina. MEASURE Evaluation is funded by the US Agency for International Development (USAID) under cooperative agreement AID-OAA-L-14-00004 and is implemented by the Carolina Population Center at the University of North Carolina at Chapel Hill, in association with ICF International; John Snow, Inc; Management Sciences for Health; Palladium; and Tulane University.

The opinions expressed in this publication do not necessarily reflect the views of USAID or the US government.

The authors declare no conflicts of interest.

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