The Free State is performing abysmally when it comes to dispensing ARVs, the percentage of HIV patients receiving a three to six-month supply of ARVs at a time having plummeted from 13% last year to 3% this year, making it SA’s worst performer in multi-month dispensing of ARVs.
In contrast, writes Refilwe Mochaoari in Spotlight, in Mpumalanga, 64% of people with HIV receive a three to six-month refill as per national guidelines.
These latest figures were revealed by community-led clinic monitoring group Ritshidze.
In its third Free State report, released in August, the group notes several challenges of people with HIV, among them being a lack of multi-month dispensing of ARVs and long waiting times at clinics, two factors making it even harder to take treatment as prescribed.
While multi-month dispensing often allows patients to collect their treatment at pick-up points at healthcare facilities or externally in the community, making it quicker and easier, the monitoring data show that 41% of people using facility pick-up points still have to collect files, take vitals, and see clinicians before getting their parcel, adding to unnecessary delays.
“Overall, these shortcomings contribute to slow progress in getting everyone to start and stay on HIV treatment,” said the report.
Monitoring for the report was done in April and May at 21 facilities and included interviews with 1 095 public healthcare users across four districts. Of those interviewed, 47% (516) were people with HIV (PLHIV) and 16% (180) were under 25.
The recommendations
The report said multi-month dispensing of ARVs is just one way to reduce the burden on the healthcare system, and the subsequent long waiting times, overcrowded clinics and overworked staff.
Ritshidze recommends – as it did in its two previous Free State reports – that “the department extends and implements refills up to three months by end December 2023, and six months by end September 2024”.
It is also recommended the department ensures people are offered a range of repeat prescription collection strategy options, “that facility pick-up points are one-stop, very quick ART collection-only, that clinic visits are under 30 minutes, and there is no need to go to the clinic registry, collect folders, and see clinicians”.
“Multi-month dispensing and repeat prescription collection strategies can simplify and adapt HIV, serving people’s needs better and reducing unnecessary burdens on the system,” the report notes.
People with HIV often report that healthcare workers send them to the back of the queue when they miss appointments, and Ritshidze recommends staff learn to acknowledge and understand the importance of ART continuity; that it is normal to miss appointments, and that no one with HIV should be sent to the back of the queue for missing an appointment – as per the welcome back campaign strategy.
Ritshidze also recommends clinics not require transfer letters to restart or continue with ART and any reports where treatment is delayed by healthcare workers requiring a transfer letter should be urgently investigated and disciplinary action taken.
Value of multi-month dispensing
The value of multi-month dispensing is well established. Study findings on the HIV programme in Ethiopia released in May, for example, stressed that multi-month dispensing is “an integral component of differentiated HIV service delivery for people with HIV”.
Ethiopia was the first African country to implement six-month dispensing at scale.
Benefits cited by study participants included “time and cost-savings, fewer work disruptions, reduced stigma due to fewer clinic visits, better medication adherence, and improved overall health”.
Health system-level benefits included “improved quality of care, decongested facilities, reduced provider workloads, and improved record-keeping”.
Clinical director at the Southern African HIV Clinicians Society Camilla Wattrus said that asking people to visit healthcare facilities monthly to collect routine medication can place a huge strain on resources.
“Multi-month dispensing for eligible, stable patients on chronic medications, including ARVs, can alleviate some of this burden, easing up the staff’s available time for those with acute conditions and for unstable patients.”
She said multi-month dispensing reduces potential adherence barriers, leading to poor health and loss of income, like transport costs and time off work. External pick-up points can also reduce congestion and waiting times at facilities.
On how the Free State Health Department can improve its performance on multi-month dispensing, Wattrus said establishing clear eligibility criteria would work because not all patients may be suitable. She said patient education is vital so that they understand the importance of adherence.
“Knowing how to take and store medication, knowing where and when to collect medication, when to return for appointments, and understanding that they can return whenever they feel unwell or in an emergency, is very important. Adequate supply chain management to ensure an uninterrupted supply of medication, along with accurate record-keeping and communication, are vital.
“Pharmacists, prescribers, and other staff must also be trained on how to deliver multi-month dispensing.”
The reality …
However, Thabiso Chaka, founder of the lesbian, gay, bisexual, and transgender (LGBT) organisation Free State Rainbow Seeds, said the province could do more to expand external pickup points.
“Once a person has shown interest and is adhering to their medication, it is a bonus to be told you don’t have to come to the facility every month and every day, that you can come after every three to six months.
“It’s a good strategy to ensure people adhere to their treatment. The Free State is doing poorly because there is also not enough treatment viral load literacy, which creates a serious challenge, and the level of care is often compromised because facilities are congested.
“We also want to become a CCMD point where we can be able to issue three to six months because by so doing our people will be comfortable.”
CCMD (Central Chronic Medicines Dispensing and Distribution) is a government programme that enables stable patients to collect chronic medicines dispensed centrally from designated pick-up points.
Chaka said multi-month dispensing of ARVs “is a good approach to limit issues of defaulting because the stigma attached to HIV-positive people is still there”.
Judy Mokoena from the Treatment Action Campaign (TAC) in the Free State said there were many reasons why the provincial department struggled with multi-month ARV dispensing.
“One is that most facility managers and pharmacists order medication too late. Another is that they do not have an actual database of people with HIV who attend their facilities. What I have noticed is that most people in the province still receive their medication inside the facilities.
“TAC has been emphasising the issue of giving patients a three to six-month supply, but they are failing dismally,” she said. “Every year we ask the same questions when it comes to the multi-month dispensing, but there has not been a clear answer from government.
“ARV shortage and ARV theft also play a role and could be another reason why the government is struggling to provide three to six months’ supply. In the past, we have had challenges of stockouts in the province.”
Free State Government responds
Spotlight approached the district health managers in Lejweleputswa district and Thabo Mofutsanyana district for comment but they referred us to the Health communications team, who then issued a statement on Ritshidze’s findings.
Ritshidze’s report was called “a constructive model of engagement between the department and the advocacy groups”.
“The department … acknowledge the report which identifies areas of weakness in service delivery and also provides an opportunity for corrective measures to be taken and improvements effected.
“The Department of Health has outlined remedial actions… that significant improvement was made for patients receiving two months’ supply from 61% in 2022 to 87% in 2023. A provincial resolution was made for a phased-in approach for the implementation of the three-month refill, starting with patients receiving ARTs and other multi-morbidities. This resolution will be re-visited by the end of the third quarter, in December 2023.
“On PrEP, the recommendation was that there is a need to ensure HIV prevention tools, including lubricants, external and internal condoms, pre-exposure prophylaxis (PrEP), and post-exposure Prophylaxis (PEP) are made easily available at all public health facilities. A total of 6 923 clients in the province have received PrEP to date.”
In an interview with Spotlight in December last year, Free State Health spokesperson, Mondli Mvambi said the department continues to give healthcare users a two-week supply of medication at some clinics because some patients “go to clinics and steal medication”.
“We have identified people who are clinic hoppers who steal medication. When they get three months’ supply, they go to another clinic for another three months’ supply. So to curb this practice, we keep people on 14 days’ supply. The idea is to give them a few days because they claim to have forgotten their clinic cards,” he said at the time.
Meanwhile, the numbers for retaining people with HIV on treatment are not looking great in the province.
In the department’s last tabled annual report, it admitted it failed to meet its target for retaining adults on ART in care. The ART adult remain-in-care rate in 2019/20 was 68%. In 2020/21, it dropped to 52.8%, and in 2021/2022 it climbed to 67.3%.
Among the reasons given for these numbers are the high number of loss to follow-up of clients and “poor tracing by community healthcare workers due to poor supervision”.
Ritshidze-State-of-Health-Free-State-2023
See more from MedicalBrief archives:
Report shows deteriorating conditions at Free State clinics
Urgent action needed to reduce ARV clinic stockouts – Treatment Action Campaign
Free State premier unhappy with slow pace of clinic and hospital renovations