Person‐centred, integrated non‐communicable disease and HIV decentralized drug distribution in Eswatini and South Africa: outcomes and challenges

Abstract

Introduction Non‐communicable diseases (NCDs) are highly prevalent in people living with HIV above 50 years of age and account for increasing mortality. There is little published evidence supporting person‐centred, integrated models of HIV care, hypertension and diabetes treatment in southern Africa, and no data demonstrating mortality reduction. Where clinical visits for NCDs and HIV cannot be combined, integrated medication delivery presents an opportunity to streamline care and reduce patient costs. We present experiences of integrated HIV and NCD medication delivery in Eswatini and South Africa, focusing on programme successes and implementation challenges. Programmatic data from Eswatini's Community Health Commodities Distribution (CHCD) from April 2020 to December 2021 and South Africa's Central Chronic Medicines Dispensing and Distribution (CCMDD) from January 2016 to December 2021 were provided by programme managers and are summarized here. Discussion Launched in 2020, Eswatini's CHCD provides over 28,000 people with and without HIV with integrated services, including HIV testing, CD4 cell count testing, antiretroviral therapy refills, viral load monitoring and pre‐exposure prophylaxis alongside NCD services, including blood pressure and glucose monitoring and hypertension and diabetes medication refills. Communities designate neighbourhood care points and central gathering places for person‐centred medication dispensing. This programme reported fewer missed medication refill appointments among clients in community settings compared to facility‐based settings. South Africa's CCMDD utilizes decentralized drug distribution to provide medications for over 2.9 million people, including those living with HIV, hypertension and diabetes. CCMDD incorporates community‐based pickup points, facility “fast lanes” and adherence clubs with public sector health facilities and private sector medication collection units. There are no out‐of‐pocket payments for medications or testing commodities. Wait‐times for medication refills are lower at CCMDD sites than facility‐based sites. Innovations to reduce stigma include uniformly labelled medication packages for NCD and HIV medications. Conclusions Eswatini and South Africa demonstrate person‐centred models for HIV and NCD integration through decentralized drug distribution. This approach adapts medication delivery to serve individual needs and decongest centralized health facilities while efficiently delivering NCD care. To bolster programme uptake, additional reporting of integrated decentralized drug distribution models should include HIV and NCD outcomes and mortality trends.

Reasons for disengagement from antiretroviral care in the era of “Treat All” in low‐ or middle‐income countries: a systematic review

“…Another frequently reported contributing factor was transport costs or distances. Ameliorating this problem is highly context‐dependent but offering community‐based decentralized ART options [ 41 ] or social protection to offset the cost of transport might be appropriate in some settings. Psychological distress and low social support were commonly mentioned as reasons for disengaging in this review; and trial and implementation science projects investigating the effectiveness of providing service navigation and social support to men in Malawi [ 42 ] and in South Africa [ 43 ] are ongoing.…”

A people‐centred health system must be the foundation for person‐centred care in the HIV response

“…To establish a strong and successful PCHS, partnerships between health ministers and governmental agencies, nongovernmental organizations, international donors and forprofit private organizations are all important. This was noted by Goldstein et al [14] in their experience in Eswatini and South Africa, where through these public−private partnerships, they were able to develop scalable programmes for HIV and non-communicable diseases integration without requiring out-of-pocket costs to clients.…”

“…This was noted by Goldstein et al. [ 14 ] in their experience in Eswatini and South Africa, where through these public−private partnerships, they were able to develop scalable programmes for HIV and non‐communicable diseases integration without requiring out‐of‐pocket costs to clients.…”