Amid major disruptions caused by aid cuts from the United States Government, the National Department of Health aims to enrol an additional 1.1m more people with HIV on antiretroviral medicine this year.
Experts told Ufrieda Ho from Spotlight that it can’t be business as usual if this ambitious “Close the Gap” programme is to have a chance of succeeding.
Already, 5.9m of the 7.8m South Africans with HIV are on treatment, and to achieve its goals, the NDoH said specific targets have also been set for each of the provinces.
The initiative is aimed at meeting the UNAIDS 95–95–95 HIV testing, treatment and viral suppression targets endorsed in the SA National Strategic Plan for HIV, TB, and STIs 2023-2028.
Currently, South Africa stands at 96-79-94 against these targets, said the South African National Aids Council (SANAC), indicating that the biggest gap in the HIV response lies with those who have tested positive but are not on treatment – the second 95 target.
But adding 1.1m people to the HIV treatment programme in just 10 months would be unprecedented. The highest number of people starting ARV treatment in a year was the roughly 730 000 in 2011.
In each of the past five years, the number has been under 300 000, according to figures from Thembisa, the leading mathematical model of HIV in South Africa.
According to our calculations, if South Africa successfully adds 1.1m people to the HIV treatment programme by the end of 2025, the score on the second target would rise to just above 90%.
However, the abrupt Pepfar funding cuts have resulted in the work of several service-delivery NGOs grinding to a halt – and the government has not yet presented a clear plan on how it plans to fill these gaps.
“We will need bridging finance for many of these NGOs to contain and preserve their essential work until we can confer these roles and responsibilities to others,” said Professor Francois Venter of the Ezintsha Research Centre at the University of the Witwatersrand.
He said good investment in targeted funding for NGOs is vital to minimise “risks to the entire South African HIV programme” and the looming consequences of rising numbers of new HIV cases, more hospitalisations, and inevitably, deaths.
Disengaging from care
The country’s under-performance on the second 95 target is partly due to people stopping their treatment. The reasons are complex, and according to research, linked to factors like frequent relocations, meaning people have to repeatedly restart treatment at different clinics.
They also have to navigate an inflexible healthcare system.
A systematic review identified factors including mental health challenges, lack of family or social support, long waiting times at clinics, work commitments, and transport costs.
Venter added that while people are disengaged from care, they are likely to transmit the virus – and the addition of new infections on an already pressured HIV response contributes to the sluggish creep towards meeting UNAIDS targets.
The Health Department has not been strong on locating people who have been “lost” to care, added Venter. This role was largely undertaken by Pepfar-supported NGOs that are now unable to continue their work.
Inexpensive interventions
Other experts working in the HIV sector say the success of the Close the Gap campaign will come down to scrapping unsuccessful programmes and approaches, using resources more efficiently, strategic investment, and introducing creative interventions to meet the service delivery demands of HIV patients.
Key among these is improving levels of professionalism in clinics so patients can trust them enough to restart treatment.
Professor Graeme Meintjes of the Department of Medicine at the University of Cape Town said improving staff attitudes and updating public messaging and communications are inexpensive interventions that can boost “welcome back” programmes.
“The Close the Gap campaign must utilise media platforms and social media platforms to send a clear message, so people know the risks of disengagement and the importance of returning to care. The longer someone interrupts their treatment and the more frequently this happens, the more they risk opportunistic infections, severe complications, getting very sick and needing costly hospitalisations.”
Clinics need to provide friendly, professional services that encourage people to return to and stay on treatment, Meintjes added, and services need to be flexible. These could include more external medicine pick-up points, scripts filled for longer periods, later clinic operating hours, and mobile clinic services.
“We need to make services as flexible as possible. People can’t be scolded for missing an appointment – life happens. Initiating these interventions is not particularly costly, in fact it is good clinical practice and make sense in terms of health economics by avoiding hospitalisations resulting from prolonged treatment interruptions.”
The Close the Gap campaign, Meintjes added, should reassure people that treatment has advanced substantially over the decades.
The drugs work well and now have far fewer side effects, with less risk of developing resistance. More patients are stable on the treatment for longer and most adults manage their single daily tablet regime easily.
Better use of what is available, resources
Professor Linda-Gail Bekker, CEO at the Desmond Tutu Health Foundation, said getting closer to the target of 1.1m people on treatment by year-end will mean using resources better.
“Additional funding is always welcome, so are new campaigns that catalyse and energise. But we also need to stop doing the things we know don’t have good returns. For instance, testing populations of people who have been tested multiple times and aren’t showing evidence of new infections occurring in those populations,” she said.
There is also a need for better data collection and more strategic use of data. Additionally, she suggests a status-neutral approach, meaning if someone tests positive, they are referred for treatment, while those who test negative are directed to effective prevention programmes, including access to pre-exposure prophylaxis (PrEP) for anyone at high risk of exposure through sex or injection drug use.
“We need to be absolutely clear; these people aren’t going to come to us in our health facilities, or we would have found them already. We have to do the work that many of the Pepfar-funded NGOs were doing – that is, going the last mile to find the last patient and to bring them to care.”
She said the impact of the Pepfar funding cuts cannot be downplayed. “The job is going to get harder, with fewer resources that were specifically directed at solving this problem.”
Venter named another approach that has not worked – the persistence of treating HIV within an integrated health system.
Overburdened clinics have simply not coped, he added, with being able to fulfil the ideal of a “one-stop-shop” model of healthcare.
“Someone might come to a clinic with a stomach ache and be vomiting… they might be treated for that but there’s no investigation or follow-up to find out if it might be HIV-related, for instance. And once that person is out of the door, they’re gone.”
Campaign specifics still lacking
The Department of Health did not answer Spotlight’s questions about funding for the Close the Gap campaign; what specific projects will look like; or how clinics and clinic staff will be equipped or supported to find the 1.1m people. There are also scant details online of the campaign specifics.
At the 25 February campaign launch, Health Minister Dr Aaron Motsoaledi said there were still 150 000 new infections every year, and that the NDoH hoped to reach its 1.1m target through a province-by-province approach. He used the Eastern Cape as an example.
“The 1.1m figure … it’s quite big, but if you go to the provinces – the Eastern Cape needs to look for 140 000 people, for example. Then you come to their seven districts, that number becomes much less. So, one clinic could be looking for just three people,” he said.
Nelson Dlamini, SANAC’s communications manager, said the focus will be to bring into care 650 000 men, as men are known to have poor health-seeking habits. There will also be a focus on adolescents and children with HIV.
Funding for the Close the Gap campaign will not be shouldered by the Health Department alone.
“This is a multisectoral campaign. Other departments have a role to play, and these include Social Development, Basic Education, Higher Education and Training, etc, and civil society themselves,” he said, adding that the province-by-province approach was guided by new data sources.
“Last year, SANAC launched the SANAC Situation Room, a data hub which pulls data from multiple sources, to give us most accurate picture on the status of the epidemic
These include the Thembisa and Naomi model outputs and the District Health Information System and Human Sciences Research Council, and SANAC was “working to secure data sharing agreements with other sectors too”.
However, the Health Department, rather than SANAC, would provide progress reports on the 10-month project, Dlamini added.
http://46.101.136.92/SpotlightTrackingPixel.php?S=MB&A=SA_unveils_ambitious_new_HIV_campaign_amid_aid_crisis
Spotlight – SA unveils ambitious new HIV campaign amid aid crisis (Creative Commons Licence)
See more from MedicalBrief archives:
UNAIDS supports SA’s HIV medicines drive
Nearly 5m South Africans placed on new HIV medicines in four years
Nearly 5m South Africans placed on new HIV medicines in four years