Date Published: January 22, 2019
Publisher: Public Library of Science
Author(s): Simukai Shamu, Jean Slabbert, Geoffrey Guloba, Dalene Blom, Sikhulile Khupakonke, Nomea Masihleho, Julius Kamera, Suzanne Johnson, Thato Farirai, Nkhensani Nkhwashu, Cathy Maulsby.
Although current data projects South Africa potentially meeting the UN target to test 90% of all people living with HIV by 2020, linking them to HIV care remains a big challenge. In an effort to increase linkage to care (LTC) of HIV positive clients an innovative collaborative intervention between two non-governmental organisations was developed and implemented between 2016 and 2017. This paper investigated the outcome of this collaborative intervention.
We used a mixed methods approach to assess the outcome of the innovative relationship. This was done by analysing routine programmatic quantitative data on LTC between 2015 and 2017 and qualitatively interviewing five programme managers, four programme implementers and five HIV positive clients on their perceived success/failure factors. Qualitative data were analysed using thematic content analysis while LTC rates were descriptively analysed. Two consultative meetings presented draft findings to programme managers (n = 7) and implementers (n = 10) for feedback, results verification and confirmation.
In 2015 cumulative LTC rate was 27% and it rose to 85% two years post-intervention in 2017. Six themes emerged as success factors at the health system and structural levels and these include: provision of client escort services, health facility human resource capacity strengthening, inter and intra-organisational teamwork, onsite LTC, facilitated and expedited jumping of queues and shifting administrative tasks to non-clinical staff to protect nurses’ time on ART initiation. These measures in turn ensured increased, affordable and swift ART initiation of clients while strengthening client support.
We concluded that multi-faceted interventions that target both health system challenges including staff shortages, efficiencies, and extended facility opening times, and structural inadequacies, including client time and resource limitations due to poverty or nature of jobs, can help to increase LTC.
The introduction of highly active antiretroviral therapy (HAART) in 1996 has allowed people living with HIV (PLWH) to prevent opportunistic infections, reduce their infectiousness, live longer and have a better quality of life[1,2]. In order to attain these benefits one needs to be tested for HIV and linked to care. The long process of linkage to care (LTC), that includes referring to health facility, conducting CD4 count at facility, HIV staging before treatment including long procedures of negotiating and counselling to achieve readiness for enrolling for ART and long administrative paper trail has been immensely shortened by the introduction of the WHO guidelines on universal test and treat, which was translated into the UN’s 90-90-90- pragmatic goals that South Africa subsequently adopted.
The study received ethical clearance from the Foundation for Professional Development Health Research Ethics Committee.
From the quantitative data, cumulative LTC rate rose from a low of 27% (1 407 linked to care out of 5 292 HIV positive clients) in 2015 to 85% in the year 2016/2017 (4127 linked to care out of 4876 HIV positive clients). LTC continued to rise in the second year of implementation (2017/2018) to 90% (3 407 clients linked to care among the 3 766 HIV positive clients). From the qualitative data six themes emerged as LTC success factors at the health system and structural levels leading to increased, affordable and swift ART initiation of clients while strengthening client support. The themes are described below.
The study found high levels of linkage to care rates achieved through multiple facility and community based interventions at different levels by a partnership of non-governmental organisations. Six success factors found were provision of client escort services, human resource capacity strengthening at the health facility, inter and intra-organisational teamwork, onsite linkage to care, facilitated and expedited jumping of queues and shifting administrative tasks to non-clinical staff while ring-fencing nurses’ time on ART initiation. These measures not only increased linkage to care but also ensured less costly but fast client ART initiation while strengthening peer client support and reducing pressure of work among existing health facility staff.
We reported a success story of linkage to care in a low resource urban, peri-urban, and rural community as facilitated by partnerships between two private institutions in public health provision and strengthening. Interventions that target both health system challenges including staff shortages, staff efficiencies and extending service opening times, and structural inadequacies including client time and resource limitations due to poverty or nature of jobs can help to increase linkage to care. We recommend multiple interventions to increase linkage to care in community-based HIV counselling and testing programmes. We also recommend building strong partnerships for the success of the UN’s 90-90-90 HIV targets for South Africa.