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Volume 28, Supplement—December 2022

Use of Project ECHO in Response to COVID-19 in Countries Supported by US President’s Emergency Plan for AIDS Relief

Janell WrightComments to Author , Laura Tison, Helen Chun, Cristine Gutierrez, Mariangeli Freitas Ning, Rosa Elena Morales, Beatriz Lopez, James Simpungwe, Kenneth Masamaro, Nazira Usmanova, Gram Mutandi, Sudhir Bunga, and Simon Agolory
Author affiliations: US Centers for Disease Control and Prevention, Guatemala City, Guatemala (J. Wright, C. Gutierrez, M. Freitas Ning, R.E. Morales, B. Lopez); US Centers for Disease Control and Prevention, Atlanta, Georgia, USA (L. Tison, H. Chun); US Centers for Disease Control and Prevention, Lusaka, Zambia (J. Simpungwe, S. Agolory); US Centers for Disease Control and Prevention, Nairobi, Kenya (K. Masamaro); US Centers for Disease Control and Prevention, Bishkek, Kyrgyzstan (N. Usmanova); US Centers for Disease Control and Prevention, Windhoek, Namibia (G. Mutandi); US Centers for Disease Control and Prevention, Juba, South Sudan (S. Bunga)

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The US Centers for Disease Control and Prevention, with funding from the US President’s Plan for Emergency Relief, implements a virtual model for clinical mentorship, Project Extension for Community Healthcare Outcomes (ECHO), worldwide to connect multidisciplinary teams of healthcare workers (HCWs) with specialists to build capacity to respond to the HIV epidemic. The emergence of and quick evolution of the COVID-19 pandemic created the need and opportunity for the use of the Project ECHO model to help address the knowledge requirements of HCW responding to COVID-19 while maintaining HCW safety through social distancing. We describe the implementation experiences of Project ECHO in 5 Centers for Disease Control and Prevention programs as part of their COVID-19 response, in which existing platforms were used to rapidly disseminate relevant, up-to-date COVID-19–related clinical information to a large, multidisciplinary audience of stakeholders within their healthcare systems.

The onset of the COVID-19 pandemic challenged health systems worldwide, resulting in service delivery disruptions and compromised quality of care of illnesses worldwide. HIV services were no exception to this phenomenon; continuity of HIV prevention and treatment was severely affected (1). Approximate excess deaths caused by HIV and AIDS of >400,000 persons in 2020 has been estimated as a result of COVID-19–induced disruptions (1). COVID-19 has affected the global response to HIV and AIDS, and countries that implemented adaptive mitigation measures for health services’ continuity have reported fewer negative effects than countries that did not (2).

Project Extension for Community Healthcare Outcomes (Project ECHO) was launched in 2003 by the University of New Mexico Health Sciences Center (Albuquerque, NM, USA) to expand access to hepatitis C treatment for patients living in remote areas of the state. Through a hub-and-spoke model that connects spoke sites to a centrally located hub of subject matter experts through video conferencing technology, Project ECHO uses case-based learning to build communities of practice and learning among geographically distant providers practicing at different levels of the healthcare system (3). Since its inception in 2003, the ECHO model has been adapted to address a variety of healthcare workforce development needs and expanded to multiple geographic locations (4). As one of the first countries in Africa to adopt Project ECHO, Namibia connected remote clinical sites with centrally located specialists for HIV and tuberculosis (TB) medical education and care management in 2015. All major district hospitals and high-volume healthcare centers in the country are now connected by this platform.

The COVID-19 pandemic has posed numerous unforeseen challenges to HIV service delivery Programs and sites supported by the US President’s Plan for Emergency Relief (PEPFAR) have faced the need to develop and adapt creative solutions for ongoing frontline provider support and HIV service quality assurance in this context. Traditional in-person training and site visit approaches were no longer feasible or recommended because of restrictions on in-person gatherings and the priority of preserving the safety of providers and beneficiaries and limiting COVID-19 spread. We describe national and regional examples of how the Project ECHO platform was used to build capacity, rapidly and regularly disseminate evolving information on COVID-19 prevention and treatment in people living with HIV, and mentor frontline providers in resource-poor health settings supported by PEPFAR.


Respondents from a convenience sample of 9 PEPFAR-supported countries known to have implemented Project ECHO for their HIV and TB programs before the COVID-19 pandemic completed a template to capture whether and how Project ECHO was being used for COVID-19–related topics, session frequency, number of participants, cadre type, and geographic location. The study team entered the data into a Microsoft Excel ( spreadsheet for data organization and descriptive analyses. Respondents implementing COVID-19 Project ECHO sessions answered a separate open-ended questionnaire about implementation challenges, program facilitators, and lessons learned from the use of the ECHO model to address COVID-19 (Appendix). The study team entered responses in Microsoft Word and grouped common themes related to implementation-enabling factors and challenges and perceived public health benefits. This project was reviewed in accordance with US Centers for Disease Control and Prevention (CDC) human research protection procedures and was determined to be nonresearch.

HIV Project ECHO Programs Incorporating COVID-19 Topics

In 4 countries and 1 region (South Sudan, Namibia, Zambia, Kyrgyz Republic, and Central America), existing HIV Project ECHO programs were used to incorporate COVID-19 topics (Table 1). Although most of these programs targeted doctors and nurses, some also included other healthcare workers. For example, in South Sudan, ECHO sessions included participants from multiple cadres, such as clinical monitoring and evaluation staff, psychosocial counselors, laboratorians, and community health workers. Namibia included laboratorians; Zambia, pharmacists; and Kyrgyz Republic, general practitioners. Project ECHO sessions began including COVID-19 topics between January and December 2020; most started in March, around the time countries and regions began to report COVID-19 cases.

COVID-19–Focused Project ECHO Programs

In total, 4 ECHO programs (2 in Central America and 1 each in Kenya and Southern Africa) were focused on COVID-19–related content (Table 2). COVID-19 Project ECHO programs in Central America addressed laboratory-specific and clinical-specific topics. Of those 4 programs, 3 catered to audiences within the broader geographic region (2 in Central America and 1 in southern Africa). ECHO session frequency varied from weekly in the Central America COVID-19 Clinical ECHO program to biweekly for the COVID-19 Laboratory ECHO program in Central America and southern Africa and monthly for the Kenya national COVID-19 ECHO program. Similar to the HIV Project ECHO programs that incorporated COVID-19 topics, almost all programs that were COVID-19–focused included multidisciplinary participants (physicians, nurses, clinical officers, pharmacists, and laboratory staff); the exception was the Central America COVID-19 laboratory ECHO program, which only targeted laboratorians.


Enabling Factors for Implementation

Country programs using Project ECHO during the COVID-19 pandemic cited several key enabling factors for implementation. Three of four COVID-19–focused Project ECHO programs launched from existing national ECHO hubs; in doing so, those programs capitalized on previously established information technology networks, equipment, and staff knowledge of ECHO. The Central America CDC program had an existing partnership with the regional ECHO hub that hosts both the TB- and HIV-focused Project ECHO programs, which provided a foundation to rapidly launch the COVID-19–focused ECHO program. Through its established network of ECHO participants, the Central America clinical COVID-19 ECHO program quickly connected to almost 4,000 healthcare providers who had participated in HIV- and TB-focused ECHO sessions over the previous year. This immediate network enabled rapid and broad dissemination of evolving COVID-19 diagnosis and management information. Similarly, the South Sudan HIV Project ECHO hub, established in 2018, built on its existing network to incorporate COVID-19 topics into their existing HIV Project ECHO program and expanded their reach to medical teams in 40 health facilities. Zambia respondents cited the ECHO hub location within the national Ministry of Health and its connection with 10 provincial health offices throughout the country as a key enabling factor in reaching healthcare providers across the country. In Central America, support from the Executive Secretary of the Regional Ministries of Health partner (SE-COMISCA) was critical to establish regional support for Project ECHO. The CDC Central America COVID-19 Project ECHO noted that its previous experience drawing on the expertise of diverse local and national health experts from the Pan American Health Organization, ministries of health, and large hospitals, as well as local healthcare personnel, for planning, facilitation, and capacity building contributed to high attendance and reported satisfaction with sessions, which was assessed through anonymous polling at the end of sessions.

Other factors identified by country teams that aided in implementation included the virtual delivery method and reasonable time requirements of Project ECHO. Respondents in Zambia described the weekly, 60-to-90–minute format of Project ECHO sessions as “ideal to minimize disruptions in clinical duties” and noted “the flexibility of tailoring ECHO sessions to meet the specific healthcare worker COVID-19 topic needs as opposed to strict adherence to a predetermined curriculum.”

Public Health Benefit

Respondents described the perceived public health benefits of using Project ECHO to respond to COVID-19. One common theme emerged regarding the benefit of bidirectional information sharing between geographically distant frontline providers and health system leaders, which helped provide insight into the public health policy and broader service delivery challenges and ability to disseminate evolving guidelines and policies for more rapid adoption. Respondents from the Project ECHO Laboratory program in Central America indicated question-and-answer sessions were helpful in fostering dialogue between facility-level laboratory staff and national-level persons who might be responsible for influencing COVID-19 laboratory policies and procedures. The South Sudan respondents highlighted how including COVID-19 topics in their HIV Project ECHO program was “crucial to information dissemination in an extremely challenging operating environment where public health programs and impact otherwise suffer from poor physical access, limited human resource capacity, insecurity and limited-service quality oversight and supervision.”

Challenges to Implementation

Countries noted several challenges to implementing Project ECHO during and with COVID-19. Those included lack of time to identify the quantity and quality of experts who were needed to present or assist with sessions, the large volume of rapidly evolving and often difficult-to-navigate information on COVID-19 prevention and clinical management (Table 3), limited ability to maintain interactive discussion-oriented sessions while disseminating large quantities of information within the allocated time, and difficulty with long-term session planning.

Country and regional programs reported variable participation in Project ECHO sessions. In addition, CDC country staff noted information technology connectivity challenges and session-timing conflicts with clinical duties as barriers to consistent participation.


One of the limitations of this analysis is the lack of a systematic review of all Project ECHO programs globally that were implemented in response to the COVID-19 pandemic. We used a convenience sample, limiting the generalizability of observations or conclusions beyond the contributing countries. The tool to capture Project ECHO program characteristics for this analysis was limited, and a more in-depth comprehensive tool to systematically evaluate Project ECHO programs during COVID-19 is likely needed. In addition, observing the development of communities of practice, a core function of any ECHO program, might have been limited by variable participation across ECHO programs.


The COVID-19 pandemic heightened existing concerns over disruptions in healthcare service delivery and essential public health functions during public health emergencies. Project ECHO might help address some of these concerns by enabling the consistent delivery of clinical and public health updates and engaging communities of providers. The ability to connect multiple stakeholders could help strengthen service quality and system resilience in the face of new challenges such as COVID-19 and lead to potential long-term positive outcomes. Evaluating ECHO programs formally to establish implementation best practices and recommendations for the use of this platform could benefit the larger public health community in its response to future public health threats.

Dr. Wright lives in Guatemala and is the regional director for Central America for the HIV and TB Programs, Division of Global HIV & TB, Center for Global Health, Centers for Disease Control and Prevention. Previous to this role, she worked in Ukraine, Kazakhstan, and Vietnam, focusing on strengthening health systems, immunizations, health reform, and responding to the HIV epidemic.



We thank the following collaborators for their support with the development of this article: Naomi Iihoshi, Ana Maria Marroquin, Rene Santos, Cristel Rivas, Edgardo Rodriguez, Sandra Juarez, Emily Zielinski-Gutierrez, Diana Forno, Edwin Sithole, Anna Deryabina, Aigul Isakova, Begayim Akmatova, Ainura Kutmanova, Nestor Sosa, Sanjeev Arora, Bruce Struminger, Joanna Katzman, and Marc Bulterys.

This article has been supported in part by PEPFAR through CDC under the terms of the Cooperative Agreement GH002262, Establishment of a Strategic Partnership to Strengthen the Council of Ministries of Health of Central America (COMISCA) in the Central America Region under PEPFAR.



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DOI: 10.3201/eid2813.220165

Original Publication Date: December 05, 2022

Table of Contents – Volume 28, Supplement—December 2022

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Janell Wright, Centers for Disease Control and Prevention, 18 Avenida 11-37, Zona 15 Vista Hermosa 3, Guatemala 01015, Guatemala

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Page created: October 15, 2022
Page updated: December 11, 2022
Page reviewed: December 11, 2022
The conclusions, findings, and opinions expressed by authors contributing to this journal do not necessarily reflect the official position of the U.S. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors' affiliated institutions. Use of trade names is for identification only and does not imply endorsement by any of the groups named above.