An Assessment of the Actionable Drivers of HIV Outcomes: A Study of the COVida Case Management System in Three Provinces in Mozambique

The research focused on three provinces in Mozambique: Maputo, Gaza, and Nampula. Data were collected from 70 randomly selected case workers, called activistas, across six community-based organizations (CBOs). A survey questionnaire was administered to activistas, their managers, and supervisors, and project documentation was collected. The data were used to identify the combinations of modifiable case management attributes that led to improved knowledge of HIV status. Qualitative comparative analysis (QCA) was used to identify the pathways that led to improved knowledge of HIV status. The analysis revealed six pathways that consistently led to a high percentage change in HIV status knowledge. These pathways included a formal process to assign cases that considered complexity, caseload, experience, skills, and proximity. Training, the quality of care-team meetings, and/or work experience were also vital for activistas with more complex cases. Most activistas lacked out-of-pocket expenses, which allowed them to dedicate more time and energy to their beneficiaries. The study also identified the cost drivers of case management. The costing analysis revealed that the organization of the CBOs was similar, with consistent proportions of expenditures attributable to case management. The breakdown of costs to cost drivers was also consistent across CBOs, with the largest costs made up of staffing, supervision, and activista subsidies. Office costs were low, and additional training costs were incurred by more remote CBOs. The study found that the percentage of beneficiaries with HIV status unknown was consistently associated with CBOs that struggled to recruit and retain activistas. These activistas had too many cases and a high proportion of complex cases, making it difficult to address the needs of their beneficiaries. The study also identified five pathways that led to a high percentage of beneficiaries with HIV status known. These pathways included work experience, caseload near the ideal caseload, attendance at weekly care team meetings, minimal challenges, and significant training. The study's findings highlight the importance of case management in improving HIV outcomes. The results suggest that activistas with formal processes to assign cases, training, and work experience are more effective in improving HIV status knowledge. The study also emphasizes the need for CBOs to prioritize staffing, supervision, and activista subsidies to ensure effective case management. The study's recommendations include implementing formal processes to assign cases, providing training and support to activistas, and prioritizing staffing and supervision to improve HIV outcomes.