National HIV Treatment Program - South Africa, April 2010

Name: Aimalohi Ahonkhai
Dates of Travel: 4/11/10-4/25/10

International program name: Catholic Relief Services: South Africa/South African Catholic Bishops Conference National HIV Treatment Program
Program amd location:
Antiretroviral Program, Catholic Relief Services, South Africa

Background:
I am conducting a retrospective cohort study of adults receiving HIV/AIDS care in the CRS/SACBC HIV treatment program in South Africa. In South Africa like many resource-poor communities, HIV care has been rapidly scaled up. Despite these efforts, HIV remains under diagnosed, and many patients once diagnosed are not linked to HIV treatment programs. Many others are not receiving life-saving therapy despite clinical eligibility, and still others do not remain in care over time. Given the myriad of challenges to providing high-quality HIV care, the aim of my study is to understand the care systems in place, and the components of these care systems responsible for the best patient outcomes, namely survival and retention in care.

I utilized this travel experience to conduct focus groups at 8 of the 14 primary HIV treatment programs in the CRS/SACBC network located in 4 provinces throughout the country. These 14 treatment programs are affiliated with an additional 57 satellite programs responsible for greater than 60,000 patients receiving HIV care in South Africa. The purpose of the focus groups was two-fold; first, to brainstorm with key clinic staff including physicians, nurses, clinic managers, social workers, and home-based care givers to understand the models of care utilized, and the elements of their programs that they identified to be the most important for providing high quality care; and second, to pilot a questionnaire developed to assess the scope and variation of services provided at different program sites.

Summary of Findings:
The CRS/SACBC HIV treatment program is a unique church-based NGO that has been providing antiretroviral treatment to HIV-infected patients in South Africa since 2004. The program was born out of home-based care projects developed by the Catholic Church in response to community needs spanning HIV care, homes for orphans and vulnerable children, hospice programs, schools, drug and alcohol rehabilitation programs, and economic development initiatives. The facilities have adapted their HIV programs to adapt to local circumstances, and with a large clinical database, provide a unique opportunity to study program features associated with high quality HIV care.

Components of Successful HIV Programs:
Program staff described several components of successful HIV programs, but most agreed that the attitude and approach of staff, ongoing patient education, and on-site social work services were key program characteristics that distinguished CSR/SACBC programs from many private practitioners and governmental programs. As a result, staff report that their patients feel less stigmatized, are more knowledgeable about their disease, and are more compliant with their treatment plans. Program staff felt that a combination of the attitude and approach of staff in addition to strong, committed program leadership also ensured consistent availability of ART medications and services, and prompt initiation of treatment for patients who are eligible. Nearly all programs were born out of strong home-based care networks run either by the Catholic Church sites themselves or collaborating NGOs. Thus, home-based care continues to be a central feature of all of the treatment programs in the CRS/SACBC network. One large treatment program based in a mining community described that their patients were seen up to 4 days per week by home based caregivers who live in their communities. Such a network may be helpful in facilitating HIV testing, linkage to care, and retention in care. Finally, a new electronic medical record system was rolled out within the CRS/SACBC network over the preceding year. Nearly all program staff reported that the electronic record significantly improved program capacity to systematically identify patients who had defaulted from care, and to maximize the home based care network in order to follow-up these patients and encourage them to return.

Challenges to Delivering High Quality Care:
Program staff identified several challenges to providing high quality HIV care. Paramount among them was stigma. All agreed that stigma & strong cultural beliefs about HIV infection remain alive and well in the communities served by the programs surveyed. These beliefs and stigma contributed to delays in presentation, defaulting from care, and distrust of the Western medical system. Program staff also agreed that inappropriate delays in tuberculosis diagnosis and treatment make it extremely challenging to provide efficient HIV care to often the sickest of HIV-infected patients. None of the CRS/SACBC programs are currently licensed to provide tuberculosis treatment, though they continue to lobby for this so that that HIV and tuberculosis care can be fully integrated. Finally, with increased focus on reducing program attrition rates, program staff report that despite intensive efforts, some patients are simply difficult to track because of a predominance of informal settlements and migrant communities which make home addresses fleeting at best.

Models of Care:
While all programs employ 1 (or more) physician(s), a team of nurses or nurse assistants, counselors, and home based care-givers, several distinct models of care have emerged that I have grouped into four categories and hope to explore further in my analysis.
• Centralized clinic (usually hospital-based) with down-referral sites
       o Patients are referred from centralized clinics to down-referral primary health care sites which are often less resourced once stable on antiretroviral therapy
• Centralized clinic with independent community satellites
       o Community satellites are opened as program expands to improve accessibility for patients. Clinic staff are typically shared between the centralized clinic and community satellites.
• Centralized clinic with patients transported from remote satellites
      o Patients are transported into to centralized clinic from designated satellite regions to improve accessibility.
• Centralized, stand-alone clinic without down-referral or satellite sites
Next Steps:
Modify Questionnaire based on focus group feedback (completed)
IRB Approval for Questionnaire
Administer Questionnaire
Data Analysis
Details for the next potential resident rotator:
While my travel was research related, within the CRS/SACBC network, there are many opportunities for clinical rotations for those who might desire this experience.