Date Published: August 31, 2017
Author(s): Saul Cobbing, Jill Hanass-Hancock, Hellen Myezwa.
People living with HIV (PLHIV) are living longer lives but are at a greater risk of developing disability. South Africa has the largest antiretroviral therapy (ART) programme in the world, shifting HIV from a deadly to a chronic disease. The integration of rehabilitation into chronic care is therefore now crucial to ensure the highest quality of life of PLHIV.
To describe how a home-based rehabilitation (HBR) programme adhered to the fundamental principles of a theoretical model of integrated care developed for the study setting in KwaZulu-Natal, South Africa.
The process and results from the HBR programme were assessed in relation to the model of care to ascertain which principles of the model were addressed with the HBR programme and which elements require further investigation.
The HBR programme was able to apply a number of principles such as evidence-based practice, task shifting to lay personnel, enabling patient-centred care and maximising function and independence of PLHIV. Other elements such as the adoption of a multidisciplinary approach, training on the use of disability screening tools and the use of evidence to influence policy development were more difficult to implement.
It is possible to implement elements of the integrated model of care. Further research is needed to understand how principles that require further training and collaboration with other stakeholders can be implemented. The results of this study provide additional evidence towards understanding the feasibility of the theoretical model and what is required to adjust and test the full model.
Following more than a decade of activism by human rights’ and civil society organisations,1 3.4 million people living with HIV (PLHIV) in South Africa have thus far gained access to the largest antiretroviral therapy (ART) programme in the world. HIV has shifted from a deadly disease to a chronic condition requiring lifelong medication. The population currently on ART constitutes approximately half of the total number of PLHIV in South Africa.2 Even greater access to ART could be achieved by the recent removal of CD4 criteria from South African ART treatment guidelines,3 which further re-emphasises the approach of universal access to ART. This policy is also promoted thorough the ambitious UNAIDS 90-90-90 targets4 and the new World Health Organization (WHO) guidelines on antiretroviral treatment.5 However, activists, healthcare workers (HCWs) and scientists in South Africa are now shifting their attention beyond access to treatment towards increased access to a continuum of care that ensures quality of life for PLHIV.6 Lazarus et al.7 propose a ‘fourth 90’ target, which should aim to ensure that 90% of PLHIV with viral suppression have good health-related quality of life, while Hanass-Hancock et al.8 call for 100% of services for PLHIV to be able to link to mitigating services like rehabilitation.
For the purposes of this article, the authors use the Chetty model to assess if the intervention was able to apply the fundamental principles of the model. A comparison of the overall study in relation to the Chetty model was undertaken using a desk review to assess how the process and results of the study adhere to the fundamental principles of this model as well as to highlight areas that were not adequately addressed. The first author took the lead on this task, after which the two co-authors (who were research supervisors for this study and who have conducted other research in this area) analysed and revised this comparison where necessary.
Table 3 indicates which of the principles of the Chetty model this study was able to implement and how each principle was addressed.
The assessment described above suggests that the development and implementation of the HBR programme were able to adhere to the majority of the fundamental principles of the Chetty model. The fact that trained CCWs were able to safely implement the HBR intervention provides empirical support for a task shifting approach to the rehabilitation management of PLHIV. Task shifting has been defined as the reassignment of specific tasks to different cadres of HCWs33 and has been proposed as a solution to the shortage of health professionals in South Africa.34 Indeed, it has been demonstrated in the same study location that appropriately trained lay counsellors can effectively deliver group-based counselling for PLHIV with co-morbid depression.35 Similarly the Framework and Strategy on Disability and Rehabilitation Services in South Africa12 promotes the rehabilitation of patients in their own homes and the training of CCWs to detect disability and refer appropriately. The participants recruited for the HBR intervention in this study were selected from an existing cohort who had already been screened for potential mobility limitation.11 The CCWs working on the intervention were not trained to identify disability, however, and thus the study did not include a fundamental principle of the Chetty model of care, namely to train all workers on the use of disability screening tools. Hence, future research needs to identify feasible strategies using simplified screening and referral tools to enable and train healthcare staff at all levels to screen, identify and refer individuals with functional limitations. The pilot workshops included in the overall project echo this analysis as they revealed that HCWs can address certain elements of disability-inclusive healthcare services (for example the creation of disability help desks) but that others elements of care such as screening for disability and referral to rehabilitation services needs more long-term planning and innovation.20
This article has shown how the HBR intervention, designed and assessed in this study, complements a wider model of chronic care for PLHIV that has been developed in the same resource-poor location. Study participants were provided with safe, evidence-based and accessible patient-centred rehabilitation using a task shifting paradigm that empowered and trained lay care workers from the study community. The assessment of this study within the wider Chetty model has the potential to further inform pragmatic implementation strategies that may enhance the health-related quality of life of PLHIV and provide alternative rehabilitation options, particularly for people experiencing disability in resource-poor communities. Such a trial needs to integrate the approach from this study and other fundamental principles of the model of care that this HBR intervention did not seek to address. These elements include the adoption of a multidisciplinary approach throughout the research process, the investigation of programme cost-effectiveness and potential training approaches for disability screening. Evidence of this nature could then be used to inform policy development and ultimately the translation of theory into practice. As more and more PLHIV gain access to effective treatment and live longer lives, it is imperative that HCWs, advocates, researchers, communities and wider stakeholders form collaborations that focus on providing the appropriate policy and operational structures to ensure that rehabilitation is widely included in the management and care of this population. This will give PLHIV the best possible chance of achieving a better health-related quality of life and the opportunity to participate more fully in all of their life pursuits.