A Case Study of an Effective and Sustainable Antiretroviral Therapy Program in Rural South Africa

Abstract

The delivery of high-quality HIV care in rural settings is a global challenge. Despite the successful expansion of antiretroviral therapy (ART) in Africa, viral load (VL) monitoring and ART adherence are poor, especially in rural communities. This article describes a case study of an ART program in the deeply rural Eastern Cape of South Africa. The Zithulele ART Program initiated five innovations over time: (1) establishing district hospital as the logistical hub for all ART care in a rural district, (2) primary care clinic delivery of prepackaged ART and chronic medications for people living with HIV (PLH), (3) establishing central record keeping, (4) incentivizing VL monitoring, and (5) providing hospital-based outpatient care for complex cases. Using a pharmacy database, on-time VL monitoring and viral suppression were evaluated for 882 PLH initiating ART in the Zithulele catchment area in 2013. Among PLH initiating ART, 12.5% (n = 110) were lost to follow-up, 7.7% (n = 68) transferred out of the region, 10.2% (n = 90) left the program and came back at a later date, and 4.0% (n = 35) died. Of the on-treatment population, 82.9% (n = 480/579) had VL testing within 7 months and 92.6% (n = 536/ 579) by 1 year. Viral suppression was achieved in 85.2% of those tested (n = 457/536), or 78.9% (n = 457/579) overall. The program's VL testing and suppression rates appear about twice as high as national data and data from other rural centers in South Africa, despite fewer resources than other programs. Simple system innovations can ensure high rates of VL testing and suppression, even in rural health facilities.

Implementation of South Africa’s Central Chronic Medicine Dispensing and Distribution Program for HIV Treatment: A Qualitative Evaluation

“…Our study suggests several avenues for future research. Although case studies of differentiated ART delivery models in South Africa suggest effects on improved health outcomes [ 42 ], there is a need to test the comparative effectiveness of CCMDD versus standard clinic ART provision on increased viral load suppression and retention in care, overall and by pick-up point type (e.g., in-clinic, external, smart lockers). Research is also needed to document numbers and types of patients for whom CCMDD is infeasible (e.g., rural patients who do not live near pick-up points or without transportation access).…”

Quality of antiretroviral therapy services in Ghana: Implications for the HIV response in resource-constrained settings

“…In this study, viral load testing appears to be a main challenge facing ART sites located in peri-urban and rural areas due to absence of equipment, comparable to studies conducted elsewhere on accessibility to ART services. 45,46,47,48,49,50,51 Similarly, CD4 count reagents were also found to be in short supply across all facilities studied, partly due to the introduction of the treat-all policy which recommends that irrespective of CD4 count level, treatment should be initiated in order to ensure quick and immediate enrolment into ART care. 13 In light of this, national survey to include other sentinel facilities across the 16 regions of Ghana can be done to arrive at a more concrete conclusion.…”

Viral Load Monitoring for People Living with HIV in the Era of Test and Treat: Progress Made and Challenges Ahead – A Systematic Review

“…Screening titles and abstracts identi ed 66 studies for full-text examination, of which 32 studies met the inclusion criteria and were included. Bibliography review identi ed two additional studies, making a total of 34 studies included in the review (Figure 1) Twenty-nine of the 34 included studies were conducted in and/or had data collected from sub-Saharan Africa (SSA) countries, including South Africa [21][22][23][24][25][26][27][28][29][30][31],…”

“…Of 11 studies from South Africa, four were conducted in Cape Town, reporting relatively high VL coverage of 72-89% [22,[24][25][26]. Other studies were conducted in KwaZulu-Natal [21,30,31], Eastern Cape [23,27] and Gauteng [29], and another study [28] included data from ART patients in nine different provinces across the country. Studies with interventions to improve quality of ART program had a VL coverage of >90% whilst other studies reported a VL range of 25%-81%.…”

“…Therefore, it is critical to strengthen local health system capacity to maintain desirable outcomes when direct external support declines. Studies from rural South Africa showed that implementation and outcome of VL monitoring programs could vary signi cantly, independent of the level of funding and staff [21,23,25], highlighting the importance of a health system approach for e cient use of available resources to deliver HIV services. Operational research is needed to identify cost-effective interventions and best practices to improve VL outcomes for PLHIV in LMICs.…”