Over the last decade, linkage to care has been a key weakness in the South African national ART program. In May 2016, following recommendations of the World Health Organization (WHO 2015), the South African government announced the phased rollout from September 2016 of a Universal Test and Treat (UTT) strategy, initially to key populations and then to the general adult population, prioritizing certain clinical categories (DOH 2016, Pinini 2016). Early adopters have commenced uptake of UTT, although the majority of general adult patients have been slow to take up immediate initiation onto ART (personal communication, Catherine White). Experience with implementation of pMTCT Option B+ in South and Sub-Saharan Africa has shown that, even when immediate initiation on ART is available, psychosocial and health systems factors have contribute to delays for many patients in initiating ART (Ciaranello et al. 2012, Kieffer et al 2014). Nevertheless, caution has been expressed about offering ART to greater numbers of people until the health system is able to enhance linkage to and retention in HIV care.
This project has the potential to make an important contribution, as enhancing linkage to and retention in care is very important if the UTT strategy is to achieve its full potential impact on the epidemic. Furthermore, the interventions combined with program monitoring through routine data will improve district and facility HIV services, offer much-needed epidemiological information at national level to further strengthen the HIV program, and assist South Africa in reaching UNAIDS 90-90-90 targets to improve the health of the population.
Aim
The aim of this project is to strengthen district-level capacity to enhance linkage to and retention in HIV care, through implementation of a combination of interventions and through strategic use of routine programmatic information, as UTT is adopted by the general adult population in South Africa. Specific objectives are:
- To review and monitor linkage to and retention in care, the drivers and health impacts thereof, using and comparing routine programmatic data and information collected from patient interviews, in participating primary health care facilities within UThukela district;
- To develop and implement, with a process evaluation, facility-based quality improvement interventions to strengthen processes, quality and utilisation of routine data, in order to enhance linkage to and retention in HIV care;
- To implement and undertake a process evaluation of a gender-sensitive coping and adjustment intervention, seeking to enhance linkage to and retention in HIV care;
- Based on findings of the process evaluation, to develop materials and recommend strategies for scaling up interventions to enhance linkage to and retention in HIV care, to support progress towards targets for the UNAIDS 90-90-90 strategy in South Africa.
Methods
Mixed methods will describe the following: 1) initial experience, 2) impact on linkage, and 3) impact on retention in HIV care of a combination of interventions for adults newly diagnosed with HIV, in a single high-prevalence rural district over a period of two and a half years. After a pre-intervention enrolment period of 6 months, a combination of interventions will be implemented in 17 primary health care facilities in UThukela district, and assessed through a process evaluation involving 17 months of prospective data collection.
Patient-level data on human subjects will be collected and triangulated between various sources, to contribute to a pre/post evaluation of the interventions and to provide monitoring of the uptake of UTT by the general adult population in this district.
Rather than setting up parallel systems, the approach to the programmatic monitoring components will be to support public sector health workers and managers in collection and utilization of the routine data which they are required to collect by Department of Health monitoring and evaluation frameworks.
