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Outcomes from a community-led monitoring (CLM) intervention in Malawi and South Africa
Abstract Content:
BACKGROUND: Since 2020, more than $100 million has been invested in community-led monitoring (CLM), globally. To date, CLM research largely centres on the identification of issues with HIV services and barriers to access. Few studies show how CLM leads to concrete changes in service uptake or health outcomes. Rigorous evaluation methods are needed to demonstrate the effectiveness of the intervention.
METHODS: Community-led organizations systematically collected data on HIV prevention and treatment services from 33 health facilities in Malawi and South Africa between November 2020 and October 2024 (four years). They routinely fed this data back to decision-makers to inform service improvements. At the end of the project, we compared outcomes at the CLM sites with the other health facilities in the focus districts by analyzing DHIS2. We also investigated whether more intensive CLM was associated with improved results. We calculated odds ratios (ORs) to determine the effect of the CLM intervention.
RESULTS: Recipients of care at CLM sites were more likely to initiate pre-exposure prophylaxis compared to other facilities (1.32 OR 95% CI 1.27-1.38). Pregnant women at CLM sites were twice as likely to deliver in the health facility, reducing the risk of vertical transmission (1.99 OR 95% CI 1.51-2.62). The CLM sites were also more likely than non-CLM sites to find and diagnose adolescent girls and young women (AGYW) living with HIV (1.46 OR 95% CI 1.28-1.66). As a result, the cost to diagnose one AGYW living with HIV was $2,852 at the CLM sites compared to $4,154 at the non-CLM sites. More intensive CLM was associated with improved service coverage and health outcomes. At CLM sites with additional resources for community scorecards, community mobilization, and community dialogues, people living with HIV were six times more likely to access treatment through a differentiated service delivery model (6.79 OR 95% CI 6.04-7.63). People at the intensive CLM sites were twice as likely to be virally suppressed compared to the standard CLM intervention (2.34 OR 95% CI 2.16-2.54).
CONCLUSIONS: It is possible to evaluate CLM interventions using rigorous scientific methods. Identifying a control group can be helpful to demonstrate the effectiveness of CLM.
METHODS: Community-led organizations systematically collected data on HIV prevention and treatment services from 33 health facilities in Malawi and South Africa between November 2020 and October 2024 (four years). They routinely fed this data back to decision-makers to inform service improvements. At the end of the project, we compared outcomes at the CLM sites with the other health facilities in the focus districts by analyzing DHIS2. We also investigated whether more intensive CLM was associated with improved results. We calculated odds ratios (ORs) to determine the effect of the CLM intervention.
RESULTS: Recipients of care at CLM sites were more likely to initiate pre-exposure prophylaxis compared to other facilities (1.32 OR 95% CI 1.27-1.38). Pregnant women at CLM sites were twice as likely to deliver in the health facility, reducing the risk of vertical transmission (1.99 OR 95% CI 1.51-2.62). The CLM sites were also more likely than non-CLM sites to find and diagnose adolescent girls and young women (AGYW) living with HIV (1.46 OR 95% CI 1.28-1.66). As a result, the cost to diagnose one AGYW living with HIV was $2,852 at the CLM sites compared to $4,154 at the non-CLM sites. More intensive CLM was associated with improved service coverage and health outcomes. At CLM sites with additional resources for community scorecards, community mobilization, and community dialogues, people living with HIV were six times more likely to access treatment through a differentiated service delivery model (6.79 OR 95% CI 6.04-7.63). People at the intensive CLM sites were twice as likely to be virally suppressed compared to the standard CLM intervention (2.34 OR 95% CI 2.16-2.54).
CONCLUSIONS: It is possible to evaluate CLM interventions using rigorous scientific methods. Identifying a control group can be helpful to demonstrate the effectiveness of CLM.