Differences in access and patient outcomes across antiretroviral treatment clinics in the Free State province: A prospective cohort study

Ingle, Suzanne M; May, Margaret T; Uebel, Kerry; Timmerman, Venessa; Kotzé, Eduan; Bachmann, Max; Egger, Matthias; Fairall, Lara

doi:10.7196/samj.3952

Cited by 18 publications

(13 citation statements)

References 23 publications

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“…4,6 Further motivation to rapidly improve access is evidence showing that more than 80% of deaths during the first year after diagnosis of HIV infection occurred before these patients could be started on ART. 7 Because of the need to scale-up access to ART, President Zuma announced on World AIDS Day, 1 December 2009, that any citizen would be able to access counselling, testing and treatment at any health centre. 8 This meant increasing the number of sites providing ART from 496 to 4 333.…”

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confidence: 99%

Nurse-initiation and maintenance of patients on antiretroviral therapy: Are nurses in primary care clinics initiating ART after attending NIMART training?

et al. 2012

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Despite the remarkable achievement of the scale-up of antiretroviral therapy (ART) in South Africa over the past 7 years (about 1 million people on ART), the estimated number of people (1.2 million) requiring treatment in the next 2 years exceeds the capacity of the healthcare system if treatment continues to be initiated only by doctors. [1][2][3] In South Africa, there are 69 doctors and 388 nurses per 100 000 population.3 Task-shifting from doctors to nurses for initiating and maintaining ART is a logical strategy to meet the need of increased access.2,4,5 Nurse initiation and maintenance of antiretroviral therapy (NIMART) improves access, is cost effective, is not inferior to doctormanaged ART, and achieves similar outcomes of viral suppression, adherence, toxicity and death. 4,6 Further motivation to rapidly improve access is evidence showing that more than 80% of deaths during the first year after diagnosis of HIV infection occurred before these patients could be started on ART. 7Because of the need to scale-up access to ART, President Zuma announced on World AIDS Day, 1 December 2009, that any citizen would be able to access counselling, testing and treatment at any health centre.8 This meant increasing the number of sites providing ART from 496 to 4 333. 9 The Acting Director-General of Health, Dr K Chetty, authorised professional nurses who had the necessary training and supervision to initiate HIV-infected patients on ART from 1 April 2010.The Foundation for Professional Development (FPD) developed a 5-day NIMART training course that included a revision of basic HIV and opportunistic infections in adults and children, the appropriate investigations, and diagnosis and treatment of HIV, TB and STIs. The theory was reinforced by case study discussions and role-play exercises using the approach of the Integrated Management of Childhood Infections (IMCI) and Practical Approach to Lung Health and HIV/AIDS (Palsa Plus).Large-scale training of nurses in 7 provinces began in October 2010; by the end of March 2011, 1 736 nurses had attended one of the 39 NIMART courses facilitated by FPD faculty. All participants received a study manual containing all the lecture notes and a file containing the national guidelines on the management of HIV, TB, INH prophylactic therapy (IPT), prevention of mother-to-child transmission (PMTCT) and sexually transmitted infections. The Hlabisa Casebook, a pocket guide of drug interactions and a service directory of health resources in each province were also supplied. Each nurse received a laminated card with the telephone number of the HIV helpline (0800212506). This free service gives the caller access to advice from a clinical pharmacist in the Department of Pharmacology at the University of Cape Town. Nurses were also encouraged to contact the FPD faculty member facilitating the course, if they had clinical questions.A 60-question multiple choice open book test, with a pass mark of 70%, was administered on the last day of the course. Those who did not pass were given 2 opportuni...

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Nurse-initiation and maintenance of patients on antiretroviral therapy: Are nurses in primary care clinics initiating ART after attending NIMART training?

et al. 2012

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“…In this study, although no statistically significant factors associated with retention in pre-ART care were found, the odds ratios suggested that females and those knowing someone on ART were more likely to be retained in pre-ART care. Likewise, a range of factors associated with retention in or loss to pre-ART care have been described in other studies [6], [11], [12], [23], [24]. In a study in KwaZulu -Natal retention in pre-ART care was associated with female sex as well as a lower initial CD4 count and older age [12].…”

Section: Discussionmentioning

confidence: 70%

“…In a study in KwaZulu -Natal retention in pre-ART care was associated with female sex as well as a lower initial CD4 count and older age [12]. Factors influencing loss to pre-ART care included distance from the health centre [6], [11] male sex [6], [11], [23] a low CD4 count [6], [11] a history of being treated for TB, referral for HIV testing by a health care provider as opposed to self-referral, weight below 50 kg, unemployment [11] and younger age [23]. A qualitative study, as part of the researching equity in access to healthcare (REACH) project, found that continuing adherence to ART was positively affected by social and economic support by families, friends and the broader community, and negatively by transport and food costs [25].…”

Section: Discussionmentioning

confidence: 99%

“…Recent changes in guidelines increasing CD4 eligibility to initiate ART may help to improve this. Poor access to, or poor retention in pre-ART care, may contribute to the low baseline CD4 at ART initiation, which is associated with high mortality [6].…”

Section: Introductionmentioning

confidence: 99%

“…The target is for 80% of men and women aged 15–49 years (30 million) to have been tested for HIV by 2016 [1]. CD4 cell count monitoring should occur at six monthly intervals in PLWH not yet eligible for ART and they should be retained in pre-ART care [1], [6], [7].…”

Section: Introductionmentioning

confidence: 99%

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Missed Opportunities for Retention in Pre-ART Care in Cape Town, South Africa

et al. 2014

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BackgroundFew studies have evaluated access to and retention in pre-ART care.ObjectivesTo evaluate the proportion of People Living With HIV (PLWH) in pre-ART and ART care and factors associated with retention in pre-ART and ART care from a community cohort.MethodsA cross sectional survey was conducted from February – April 2011. Self reported HIV positive, negative or participants of unknown status completed a questionnaire on their HIV testing history, access to pre-ART and retention in pre-ART and ART care.Results872 randomly selected adults who reported being HIV positive in the ZAMSTAR 2010 prevalence survey were included and revisited. 579 (66%) reconfirmed their positive status and were included in this analysis. 380 (66%) had initiated ART with 357 of these (94%) retained in ART care. 199 (34%) had never initiated ART of whom 186 (93%) accessed pre-ART care, and 86 (43%) were retained in pre-ART care. In a univariable analysis none of the factors analysed were significantly associated with retention in care in the pre-ART group. Due to the high retention in ART care, factors associated with retention in ART care, were not analysed further.ConclusionRetention in ART care was high; however it was low in pre-ART care. The opportunity exists, if care is better integrated, to engage with clients in primary health care facilities to bring them back to, and retain them in, pre-ART care.

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Decentralising HIV treatment in lower- and middle-income countries

Kredo

Ford

Adeniyi

et al. 2013

Cochrane Database of Systematic Reviews

126

117

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BACKGROUND: Policy makers, health staff and communities recognise that health services in lower-and middle-income countries need to improve people's access to HIV treatment and retention to treatment programmes. One strategy is to move antiretroviral delivery from hospitals to more peripheral health facilities or even beyond health facilities. This could increase the number of people with access to care, improve health outcomes, and enhance retention in treatment programmes. On the other hand, providing care at less sophisticated levels in the health service or at community-level may decrease quality of care and result in worse health outcomes. To address these uncertainties, we summarised the research studies examining the risks and benefits of decentralising antiretroviral therapy service delivery. OBJECTIVES: To assess the effects of various models that decentralised HIV treatment and care to more basic levels in the health system for initiating and maintaining antiretroviral therapy. METHODS: Search methods: We conducted a comprehensive search to identify all relevant studies regardless of language or publication status (published, unpublished, in press, and in progress) from 1 January 1996 to 31 March 2013, and contacted relevant organisations and researchers. The search terms included "decentralisation", "down referral", "delivery of health care", and "health services accessibility". Selection criteria: Our inclusion criteria were controlled trials (randomised and non-randomised), controlled-before and after studies, and cohorts (prospective and retrospective) in which HIV-infected people were either initiated on antiretroviral therapy or maintained on therapy in a decentralised setting in lower-and middle-income countries. We define decentralisation as providing treatment at a more basic level in the health system to the comparator. Data collection and analysis: Two authors applied the inclusion criteria and extracted data independently. We designed a framework to describe different decentralisation strategies, and then grouped studies against these strategies. Data were pooled using random-effects metaanalysis. Because loss to follow up in HIV programmes is known to include some deaths, we used attrition as our primary outcome, defined as death plus loss to follow-up. We assessed evidence quality with GRADE methodology. MAIN RESULTS: Sixteen studies met the inclusion criteria, all but one were from Africa, comprising two cluster randomised trials and 14 cohort studies. Antiretroviral therapy started at a hospital and maintained at a health centre (partial decentralisation) probably reduces attrition (RR 0.46, 95% CI 0.29 to 0.71, 4 studies, 39 090 patients, moderate quality evidence). There may be fewer patients lost to care with this model (RR 0.55, 95% CI 0.45 to 0.69, low quality evidence). We are uncertain whether there is a difference in attrition for antiretroviral therapy started and maintained at a health centre (full decentralisa

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Differences in access and patient outcomes across antiretroviral treatment clinics in the Free State province: A prospective cohort study

Cited by 18 publications

References 23 publications

Nurse-initiation and maintenance of patients on antiretroviral therapy: Are nurses in primary care clinics initiating ART after attending NIMART training?

Nurse-initiation and maintenance of patients on antiretroviral therapy: Are nurses in primary care clinics initiating ART after attending NIMART training?

Missed Opportunities for Retention in Pre-ART Care in Cape Town, South Africa

Decentralising HIV treatment in lower- and middle-income countries

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