title: Sustaining the future of HIV counselling to reach 90-90-90: a regional country analysis.
abstract: Counselling services are recommended by the World Health Organization and have been partially adopted by national HIV guidelines. In settings with a high HIV burden, patient education and counselling is often performed by lay workers, mainly supported with international funding. There are few examples where ministries of health have been able to absorb lay counsellors into their health systems or otherwise sustain their work. We document the role of lay cadres involved in HIV testing and counselling and adherence support and discuss approaches to sustainability.
  
  
  
  We focused on a purposive sample of eight sub-Saharan African countries where Médecins Sans Frontières supports HIV programmes: Guinea, Lesotho, Malawi, Mozambique, South Africa, Swaziland, Zambia and Zimbabwe. We reviewed both published and grey literature, including national policies and donor proposals, and interviewed key informants, including relevant government staff, donors and non-governmental organizations.
  
  
  
  Lay counsellors play a critical role in scaling up HIV services and addressing gaps in the HIV testing and treatment cascade by providing HIV testing and counselling and adherence support at both the facility and community levels. Countries have taken various steps in recognizing lay counsellors, including harmonizing training, job descriptions and support structures. However, formal integration of this cadre into national health systems is limited, as lay counsellors are usually not included in national strategies or budgeting.
  
  
  
  The current trend of reduced donor support for lay counsellors, combined with lack of national prioritization, threatens the sustainability of this cadre and thereby quality HIV service delivery.
authors.affiliation: Médecins Sans Frontières, Analysis and Advocacy Unit, Operational Centre Brussels, Brussels, Belgium; mariellebemelmans@hotmail.com.
authors.forename: Marielle
authors.initials: M
authors.lastname: Bemelmans
authors.affiliation: Médecins Sans Frontières, Southern Africa Medical Unit, Cape Town, South Africa.
authors.forename: Saar
authors.initials: S
authors.lastname: Baert
authors.affiliation: World Health Organization, Department of HIV/AIDS, Geneva, Switzerland.
authors.forename: Eyerusalem
authors.initials: E
authors.lastname: Negussie
authors.affiliation: Médecins Sans Frontières, Southern Africa Medical Unit, Cape Town, South Africa.
authors.forename: Helen
authors.initials: H
authors.lastname: Bygrave
authors.affiliation: Médecins Sans Frontières, Analysis and Advocacy Unit, Operational Centre Brussels, Brussels, Belgium.
authors.forename: Marc
authors.initials: M
authors.lastname: Biot
authors.affiliation: Médecins Sans Frontières, Operations Department, Operational Centre Geneva, Geneva, Switzerland.
authors.forename: Christine
authors.initials: C
authors.lastname: Jamet
authors.affiliation: Médecins Sans Frontières, Southern Africa Medical Unit, Cape Town, South Africa.
authors.forename: Tom
authors.initials: T
authors.lastname: Ellman
authors.affiliation: Médecins Sans Frontières, Analysis and Advocacy Unit, Operational Centre Brussels, Brussels, Belgium.
authors.forename: Amanda
authors.initials: A
authors.lastname: Banda
authors.affiliation: Department of Obstetrics, Leiden University Medical Center, Leiden, Netherlands.
authors.forename: Thomas
authors.initials: T
authors.lastname: van den Akker
authors.affiliation: World Health Organization, Department of HIV/AIDS, Geneva, Switzerland.
authors.forename: Nathan
authors.initials: N
authors.lastname: Ford
mesh_terms: D000349:Africa; D003376:Counseling; D015658:HIV Infections / Q000175:diagnosis / Q000523:psychology / Q000628:therapy*; D006801:Humans; D010353:Patient Education as Topic
keywords: HIV testing and counselling; HIV/AIDS; adherence support; antiretroviral therapy; community health workers; human resources for health; lay counsellors; lay workers; patient education and counselling; retention in care; sub-Saharan Africa; task shifting