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

Contextual Factors Influencing Implementation of HIV Treatment Support Strategies for Female Sex Workers Living With HIV in South Africa: A Qualitative Analysis Using the Consolidated Framework for Implementation Research

BACKGROUND

Female sex workers (FSWs) face a confluence of multilevel barriers to HIV care. In South Africa, 63% of FSWs are living with HIV and <40% are virally suppressed. The objective of this analysis was to identify implementation determinants of 2 HIV treatment support strategies.

METHODS

The Siyaphambili trial tested a decentralized treatment provision and an individualized case management strategy aimed to support FSWs living with unsuppressed HIV viral loads. We identified a nested sample of trial participants using maximum variation sampling (n = 36) as well as a purposively selected sample of implementors (n = 12). We used semistructured interview guides, developed using the Consolidated Framework for Implementation Research (CFIR) and deductively coded the transcripts using CFIR, systematically assessing the strength and valence of implementation. We compared construct ratings to determine whether any constructs distinguished implementation across strategies.

RESULTS

Across 3 CFIR domains (innovation characteristics, inner setting, and outer setting), 12 constructs emerged as facilitating, hindering, or having mixed effects on strategy implementation. The relative advantage, design, adaptability, and complexity constructs of the innovation characteristics and the work infrastructure construct of the inner setting were strongly influential (±2 or +2). While the majority of construct valence and strength rating (9-12) were not distinguishing across strategies, we observed 3 weakly distinguishing CFIR constructs (relative advantage, complexity, and available resources).

CONCLUSIONS

Given the potential benefits of differentiated service delivery strategies, identifying the relative importance of implementation determinants facilitates transparency and evaluation, supporting future strategy design and implementation. Optimizing implementation will support addressing inequities in HIV care and treatment services.

Does type of antiretroviral therapy pick-up point influence 12-month virologic suppression in South Africa?

We assessed the impact of community- versus clinic-based medication pick-up on rates of virologic suppression in an observational cohort of adults on ART enrolled in a decentralized antiretroviral therapy program (CCMDD) in South Africa. Participants either attended clinics where they were given the choice to pick up ART in community venues or traditional clinics, or clinics where this pathway was assigned. Among 1856 participants, 977 (53%) opted for community ART pick-up at enrollment, and 1201 (86%) were virologically suppressed at one year. Because of missing data on virologic suppression, primary results are based on a model incorporating multiple imputation. In addition to age and gender, distance from clinic and year of HIV diagnosis were included in the multivariable model. There was no difference in opting for clinic- vs. community-based pick-up with regard to achieving 12-month virologic suppression (aRR 1.02, 95% CI 0.98-1.05) in clinics offering choice. There was no impact of assigning all participants to an external pick-up point (aRR 1.00, 95% CI 0.95-1.06), but virologic suppression was reduced in the clinic that assigned participants to clinic pick-up (aRR 0.87, 95% CI 0.81-0.92). These results suggest that provision of community-based ART has not reduced continued virologic suppression in the population enrolled in the CCMDD program.

Preferences for Hypertension Care in Malawi: A Discrete Choice Experiment Among People Living with Hypertension, With and Without HIV

Hypertension is the most common non-communicable disease diagnosed among people in sub-Saharan Africa. However, little is known about client preferences for hypertension care. We performed a discrete choice experiment in Malawi among people with hypertension, with and without HIV. Participants were asked to select between two care scenarios, each with six attributes: distance, waiting time, provider friendliness, individual or group care, antihypertensive medication supply, and antihypertensive medication dispensing frequency (three versus one month). Eight choice sets (each with two scenarios) were presented to each individual. Mixed effects logit models quantified preferences for each attribute. Estimated model coefficients were used to predict uptake of hypothetical models of care. Between July 2021 and April 2022 we enrolled 1003 adults from 14 facilities in Malawi; half were living with HIV and on ART for a median of 11 years. Median age of respondents was 57 years (IQR 49-63), 58.2% were female, and median duration on antihypertensive medications was 4 years (IQR 2-7). Participants strongly preferred seeing a provider alone versus in a group (OR 11.3, 95% CI 10.4-12.3), with stronger preference for individual care among those with HIV (OR 15.4 versus 8.6, p < 0.001). Three-month versus monthly dispensing was also strongly preferred (OR 4.2; 95% CI 3.9-4.5). 72% of respondents would choose group care if all other facility attributes were favorable, although PLHIV were less likely to make this trade-off (66% versus 77%). These findings have implications for the scale-up of hypertension care in Malawi and similar settings.

'Not taking medications and taking medication, it was the same thing:' perspectives of antiretroviral therapy among people hospitalised with advanced HIV disease

BACKGROUND

Despite HIV's evolution to a chronic disease, the burden of advanced HIV disease (AHD, defined as a CD4 count of < 200 cells/uL or WHO clinical Stage 3 or 4 disease), remains high among People Living with HIV (PLHIV) who have previously been prescribed antiretroviral therapy (ART). As little is known about the experiences of patients hospitalised with AHD, this study sought to discern social forces driving hospitalisation with AHD. Understanding such forces could inform strategies to reduce HIV-related morbidity and mortality.

METHODS

We conducted a qualitative study with patients hospitalised with AHD who had a history of poor adherence. Semi-structured interviews were conducted between October 1 and November 30, 2023. The Patient Health Engagement and socio-ecological theoretical models were used to guide a thematic analysis of interview transcripts.

RESULTS

Twenty individuals participated in the research. Most reported repeated periods of disengagement with HIV services. The major themes identified as driving disengagement included: 1) feeling physically well; 2) life circumstances and relationships; and 3) health system factors, such as clinic staff attitudes and a perceived lack of flexible care. Re-engagement with care was often driven by new physical symptoms but was mediated through life circumstances/relationships and aspects of the health care system.

CONCLUSIONS

Current practices fail to address the challenges to lifelong engagement in HIV care. A bold strategy for holistic care which involves people living with advanced HIV as active members of the health care team (i.e. 'PLHIV as Partners'), could contribute to ensuring health care services are compatible with their lives, reducing periods of disengagement from care.

Healthcare worker perspectives on adaptations to differentiated anti-retroviral therapy delivery during COVID-19 in South Africa: A qualitative inquiry

During the COVID-19 pandemic, the South African Centralized Chronic Medicines Dispensing and Distribution (CCMDD) programme, adapted to include extended 12-month antiretroviral therapy (ART) prescriptions, 3-months ART refills and earlier eligibility criteria at 6-months after ART initiation. We aimed to explore the experiences of healthcare workers (HCWs) in implementing these adaptations, and to understand the overall impact of COVID-19 on CCMDD. We conducted semi-structured in-depth interviews with HCWs in eThekwini District clinics, KwaZulu-Natal, South Africa. Interviews were audio-recorded, transcribed, translated, and analysed thematically. Between 18 February and 13 December 2022, we conducted 21 interviews with nurses, doctors, pharmacists, clinic managers and a community pick-up-point staff member. There were mixed perceptions about COVID-19 adaptations to CCMDD. HCWs reported that COVID-19 adaptations to CCMDD helped keep clients away from clinics, reducing exposure to COVID-19, minimizing queues, alleviating client frustration, and easing workload, which enabled more focused attention on clients with greater needs. Clients reportedly preferred 12-month prescriptions as it gave them independence. However, HCWs were concerned about clients' ART adherence, potential to miss out on clinical input, and difficulties aligning annual viral load results, during the 12 months without clinic attendance. The extended eligibility and multi-month dispensing were acceptable to HCWs, but concerns were expressed about non-adherence and stock shortages. Challenges, including staff shortages due to sickness, increased workload, inadequate training, HCWs' distrust in clients' ability to manage their health autonomously, and staff's limited involvement in decisions about the adaptations, impacted on their implementation. While HCWs reported benefits of 12-month prescribing, extended eligibility and multi-month dispensing in CCMDD, long-term implementation would require addressing concerns about impacts on adherence, alignment of annual viral loads and timely follow up. Prioritizing HCW input in decision-making processes and enhancing provider-client interactions will be pivotal in ensuring the effectiveness of CCMDD adaptations.

Estimating the Effect of COVID-19 Pandemic Restrictions on Self-reported Antiretroviral Therapy Use and Late Refill Visits Among People Living With HIV in Rural South Africa

BACKGROUND

People living with HIV require reliable access to and adequate supply of antiretroviral therapy (ART) for viral suppression. The Deliver Health Study, a randomized trial conducted during the COVID-19 pandemic, found that home-delivered ART significantly increased viral suppression compared with clinic-based care. The effect of changing COVID-19 alert levels on self-reported ART use has not been quantified.

SETTING

KwaZulu-Natal, South Africa.

METHODS

Adults living with HIV were followed in the Deliver Health Study during October 2019-December 2020. We used difference-in-differences (DiD) to estimate the effect of changing COVID-19 alert levels during 3 distinct periods on self-reported missed ART doses (missed 0 vs. ≥1 doses in past week) for participants receiving home-delivered vs. clinic-based refills. We additionally estimated the effect of changing COVID-19 alert levels on late clinic ART refill visits (late vs. on-time). We used relative risk regression for both binary outcomes.

RESULTS

Of 155 participants, 46% were women and the median age was 36 years. The mean number of missed weekly doses was 0.11, 0, and 0.12 in the home-delivery group and 0.09, 0.08, and 0.18 in the clinic group during periods 1, 2, and 3, respectively. There were no differences in relative risk of self-reported daily ART use between refill groups when comparing across periods [DiDperiod 2 vs. 1 = 1.05; 95% confidence interval: 0.97, 1.13 and DiDperiod 3 vs. 2 = 0.99; 95% confidence interval (CI): 0.91, 1.08]. In the clinic group, the risk of late refill visits was significantly higher during COVID-19 restrictions (vs. before alert level 5 implementation) and even after the COVID-19 alert level was downgraded to level 1 (RRperiod 2 vs. 1 = 1.83, 95% CI: 1.34, 2.51 and RRperiod 3 vs. 2 = 1.71; 95% CI: 1.43, 2.04).

CONCLUSION

The COVID-19 pandemic did not differentially impact self-reported ART adherence by the method of ART refills, but the risk of late clinic refill visits was significantly higher during COVID-19 restrictions and sustained after restrictions were loosened.

The Impact of COVID-19 Lockdown on Service Utilization Among Chronic Disease Patients in South Africa

Introduction

Globally, the COVID-19 pandemic has brought many disruptions in health service delivery. Evidence show that the pandemic has negatively affected routine healthcare utilization such as maternal and child health services, but the literature on the effect on non-communicable diseases (NCDs) is scant in South Africa. These disruptions can have long-term health and economic implications for patients.

Objective

To estimate the impact of COVID-19 lockdown on service utilization among chronic disease patients in South Africa using administrative data.

Methods

Using monthly data from the Centralized Chronic Medication Dispensing and Distribution (CCMDD) program database covering November 2018 to October 2021, we examined the effects of COVID-19 lockdown on utilization among patients receiving antiretroviral therapy (ART) medication only (ART-only), patients receiving both ART and NCD medication (ART + NCD), and patients receiving NCD medications only (NCD-only). We employed segmented interrupted time series approach to examine the changes. We stratified the analysis by socioeconomic status.

Results

We found that, overall, the lockdown was associated with increased utilization of CCMDD services by 10.8% (95% CI: 3.3%-19%) for ART-only and 10.3% (95% CI: 3.3%-17.7%) for NCD-only patients. The increase in utilization was not different across socioeconomic groups. For patients receiving ART + NCD medications, utilization declined by 56.6% (95% CI: 47.6%-64.1%), and higher reductions occurred in low SES districts.

Conclusion

Patients should be educated about the need to continue with utilization of disease programs during a pandemic and beyond. More efforts are needed to improve service use among patients with multi-morbidities.

Implementation of the Automated Medication Dispensing System-Early Lessons From Eswatini

Objectives: This article describes the implementation of an automated medication dispensing system (AMDS) in Eswatini to increase medication access and presents the early lessons from this implementation. Methods: The AMDS was installed at four health facilities across two regions through collaborative stakeholder engagement. Healthcare workers were trained, and clients who met the inclusion criteria accessed their medications from the system. Each step of the implementation was documented and summarised in this article. Results: Early lessons suggest that implementation of the AMDS is acceptable and feasible to clients and healthcare workers and that phased introduction of medication classes, commencing with antiretroviral therapy (ART) and incorporating other medications in later phases is feasible. Additionally, improved client-centred messaging and communication, consistent power supply and internet network connectivity, and scheduling medication pickup with other services increase AMDS system utilisation. Conclusion: Eswatini has many clients living with HIV and non-communicable diseases (NCDs). Easy, convenient, quick, non-stigmatising and client-centred access to ART and medication for NCDs is critical in addressing retention in care and achieving optimal treatment outcomes.

The South African community pharmacy sector-an untapped reservoir for delivering HIV services

Differentiated service delivery is recommended to improve the uptake of HIV testing and treatment for people living with HIV. One service delivery option yet to be fully capitalised on is community pharmacies. There are approximately 3,580 registered community pharmacies in South Africa. A total of 1,110 (31%) of these pharmacies are corporate chain pharmacies located in cities and towns, the remainder are individually owned, many of which are in less populated poorer settings. Community pharmacies traditionally play a pivotal role in providing health education to the populations they serve and are the first point of contact for people seeking health services, offering more convenient opening hours and shorter waiting times than public sector clinics or private doctors. As a result, patients regularly seek a variety of sexual and reproductive health services at community pharmacies such as self-testing devices for HIV, treatment for sexually transmitted diseases, and an array of reproductive health services, spanning emergency contraception to fertility advice, often signifying HIV risk. This has presented an opportunity for community pharmacies to provide access to HIV prevention and treatment to ensure the targets for HIV services set by international agencies and local government are achieved. Despite obstacles experienced with the expansion of the community pharmacist's role, exploring the potential of pharmacies to mediate the existing challenges with HIV service delivery has emerged as an important resource. Assessing the South African communities' specific HIV treatment needs and willingness to access HIV services from community pharmacies will benefit from additional research.

Patient and stakeholder perspectives on impacts of the COVID-19 pandemic on HIV and mental health care delivery in South Africa

BACKGROUND

The COVID-19 pandemic had a global impact on health systems and the delivery of health services, including for chronic conditions such as HIV. In South Africa, impacts on HIV services have widely been quantitatively described. Across different health settings, patients have also qualitatively described numerous negative impacts to their HIV care. However, patient perspectives on COVID-19 impacts to HIV care in South Africa, the largest HIV care system in the world, have been little explored to date.

METHODS

We conducted 29 semi-structured individual interviews with people living with HIV (n = 24) and providers (n = 5) in Cape Town, South Africa.

RESULTS

While most patient participants reported continued access to HIV treatment during the pandemic, many described perceiving that the quality of their care declined. Increased structural barriers were described as one contributing factor to this change. Additionally, patients described that reduced privacy in clinical interactions was a key factor negatively influencing their experience of receiving care.

CONCLUSION

Findings underscore the importance of ensuring patient privacy for HIV services even during the rearrangement of services in emergencies. It is also important to continue developing models to integrate community mental health services within HIV care delivery in South Africa.

Individual and area-level socioeconomic correlates of hypertension prevalence, awareness, treatment, and control in uMgungundlovu, KwaZulu-Natal, South Africa

BACKGROUND

Hypertension is the second leading risk factor for death in South Africa, and rates have steadily increased since the end of Apartheid. Research on the determinants of hypertension in South Africa has received considerable attention due to South Africa's rapid urbanization and epidemiological transition. However, scant work has been conducted to investigate how various segments of the Black South African population experience this transition. Identifying the correlates of hypertension in this population is critical to the development of policies and targeted interventions to strengthen equitable public health efforts.

METHODS

This analysis explores the relationship between individual and area-level socioeconomic status and hypertension prevalence, awareness, treatment, and control within a sample of 7,303 Black South Africans in three municipalities of the uMgungundlovu district in KwaZulu-Natal province: the Msunduzi, uMshwathi, and Mkhambathini. Cross-sectional data were collected on participants from February 2017 to February 2018. Individual-level socioeconomic status was measured by employment status and educational attainment. Ward-level area deprivation was operationalized by the most recent (2011 and 2001) South African Multidimensional Poverty Index scores. Covariates included age, sex, BMI, and diabetes diagnosis.

RESULTS

The prevalence of hypertension in the sample was 44.4% (n = 3,240). Of those, 2,324 were aware of their diagnosis, 1,928 were receiving treatment, and 1,051 had their hypertension controlled. Educational attainment was negatively associated with hypertension prevalence and positively associated with its control. Employment status was negatively associated with hypertension control. Black South Africans living in more deprived wards had higher odds of being hypertensive and lower odds of having their hypertension controlled. Those residing in wards that became more deprived from 2001 to 2011 had higher odds of being aware of their hypertension, yet lower odds of receiving treatment for it.

CONCLUSIONS

Results from this study can assist policymakers and practitioners in identifying groups within the Black South African population that should be prioritized for public health interventions. Black South Africans who have and continue to face barriers to care, including those with low educational attainment or living in deprived wards had worse hypertension outcomes. Potential interventions include community-based programs that deliver medication to households, workplaces, or community centers.

Retention on ART and viral suppression among patients in alternative models of differentiated HIV service delivery in KwaZulu-Natal, South Africa

Differentiated models of HIV care (DMOC) aim to improve health care efficiency. We describe outcomes of five DMOC in KwaZulu-Natal, South Africa: facility adherence clubs (facility AC) and community adherence clubs (community AC), community antiretroviral treatment (ART) groups (CAG), spaced fast lane appointments (SFLA), and community pick up points (PuP). This retrospective cohort study included 8241 eligible patients enrolled into DMOC between 1/1/2012 and 31/12/2018. We assessed retention in DMOC and on ART, and viral load suppression (<1000 copies/mL). Kaplan-Meier techniques were applied to describe crude retention. Mixed effects parametric survival models with Weibull distribution and clustering on health center and individual levels were used to assess predictors for ART and DMOC attrition, and VL rebound (≥1000 copies/mL). Overall DMOC retention was 85%, 80%, and 76% at 12, 24 and 36 months. ART retention at 12, 24 and 36 months was 96%, 93%, 90%. Overall incidence rate of VL rebound was 1.9 episodes per 100 person-years. VL rebound rate was 4.9 episodes per 100 person-years among those enrolled in 2012-2015, and 0.8 episodes per 100 person-years among those enrolled in 2016-2018 (RR 0.12; 95% CI, 0.09-0.15, p<0.001). Prevalence of confirmed virological failure was 0.6% (38/6113). Predictors of attrition from DMOC and from ART were male gender, younger age, shorter duration on ART before enrollment. Low level viremia (>200-399 copies/mL) was associated with higher hazards of VL rebound and attrition from ART. Concurrent implementation of several DMOC in a large ART program is feasible and can achieve sustained retention on ART and VL suppression.

Essential health services delivery in South Africa during COVID-19: Community and healthcare worker perspectives

Background

Between May 2020 and February 2022, South Africa's health system bore strain as it battled mitigating the coronavirus pandemic. The country's pandemic response was scrutinized. This period also brought into focus pre-existing shortcomings in the healthcare system and its governing bodies. Contextually, there is a paucity in literature on the experiences of healthcare providers and users. This study aimed to contribute information on COVID-19, with the intention of providing guidance on preparing for future infectious disease outbreaks.

Methods

Cross sectional exploratory qualitative methodology was employed using semi-structured interviews and focus group discussions with community members (CM) and healthcare workers (HCW) from two South African study sites: (a) rural Bushbuckridge (run by Agincourt Health and Socio-Demographic Surveillance Site) and (b), Regions D and F in Johannesburg Metropole.

Results

After interviewing 42 CMs and 43 HCWs, it emerged that mandated process changes while minimizing COVID-19 exposure, necessitated healthcare personnel focusing on critical care treatment at the expense of less acute ones. COVID-19 isolation protocols, extensive absenteeism and HCWs with advanced skills being perceived as more adept to treat COVID-19 patients contributed to HCWs experiencing higher workloads. Fears regarding contracting and transmitting COVID-19, suffering financial losses, and not being able to provide adequate advice to patients were recurrent themes. Dissemination of relevant information among healthcare facility personnel and communities suffered due to breakdowns in communication.

Conclusion

Concessions and novel strategies to avail medication to patients had to be created. Since providence was lacking, government needs to formulate health intervention strategies that embrace health literacy, alternate methods of chronic medication dispensation, improved communication across health care platforms and the use of telehealth, to circumvent the threats of possible further infectious disease outbreaks.

Opportunities and considerations for the design of decentralized delivery of antiretroviral therapy for female sex workers living with HIV in South Africa

BACKGROUND

In South Africa, 60% of female sex workers (FSW) are living with HIV, many of whom experience structural and individual barriers to antiretroviral therapy (ART) initiation and adherence. Community-based decentralized treatment provision (DTP) may mitigate these barriers. To characterize optimal implementation strategies, we explored preferences for DTP among FSW living with HIV in Durban, South Africa.

METHODS

Thirty-nine semi-structured in-depth interviews were conducted with FSW living with HIV (n = 24), and key informants (n = 15) including HIV program implementers, security personnel, and brothel managers. Participants were recruited using maximum variation and snowball sampling. Interviews were conducted in English or isiZulu between September-November 2017 and analyzed using grounded theory in Atlas.ti 8.

RESULTS

DTP was described as an intervention that could address barriers to ART adherence and retention, minimizing transport costs, time and wage loss from clinic visits, and act as a safety net to address FSW mobility and clinic access challenges. Respondents highlighted contextual considerations for DTP and suggested that DTP should be venue-based, scheduled during less busy times and days, and integrate comprehensive health services including psychological, reproductive, and non-communicable disease services. ART packaging and storage were important for community-based delivery, and participants suggested DTP should be implemented by sex work sensitized staff with discrete uniform and vehicle branding.

CONCLUSIONS

Incorporating FSW preferences may support implementation optimization and requires balancing of tensions between preferences and feasibility. These data suggest the potential utility of DTP for FSW as a strategy to address those most marginalized from current ART programs in South Africa.