Outcomes from the implementation of a counselling model supporting rapid antiretroviral treatment initiation in a primary healthcare clinic in Khayelitsha, South Africa

Abstract

BackgroundLengthy antiretroviral treatment (ART) preparation contributes to high losses to care between communicating ART eligibility and initiating ART. To address this shortfall, Médecins Sans Frontières implemented a revised approach to ART initiation counselling preparation (integrated for TB co-infected patients), shifting the emphasis from pre-initiation sessions to addressing common barriers to adherence and strengthening post-initiation support in a primary healthcare facility in Khayelitsha, South Africa.MethodsAn observational cohort study was conducted using routinely collected data for all ART-eligible patients attending their first counselling session between 23 July 2012 and 30 April 2013 to assess losses to care prior to and post ART initiation. Viral load completion and suppression rates of those retained on ART were also calculated.ResultsOverall, 449 patients enrolled in the study, of whom 3.6% did not return to the facility to initiate ART. Of those who were initiated, 96.7% were retained at their first ART refill visit and 85.9% were retained 6 months post ART initiation. Of those retained, 80.2% had a viral load taken within 6 months of initiating ART, with 95.4% achieving viral load suppression.ConclusionsAdapting counselling to enable rapid ART initiation is feasible and has the potential to reduce losses to care prior to ART initiation without increasing short-term losses thereafter or compromising patient adherence.

Differentiated HIV care in South Africa: the effect of fast‐track treatment initiation counselling on ART initiation and viral suppression as partial results of an impact evaluation on the impact of a package of services to improve HIV treatment adherence

“…Our results are not strong enough to confirm this, so continued monitoring of adherence to treatment schedules is important. While FTIC is designed to include post‐initiation counselling it is largely focused on initiation and showed success both here and in a previous study reported by Wilkinson et al in Khayelitsha, South Africa . The lack of retention and suppression benefits points to a need to support newly initiating patients with additional interventions.…”

“…Our study adds to the evidence supporting rapid ART initiation . Unlike previous studies, though, ours was done under routine conditions, without external resources for implementation.…”

“…One reason patients leave care before ART initiation is the complicated steps required to initiate, including numerous counselling visits and laboratory tests. To mitigate the impact such delays have on retention, several studies have demonstrated that rearranging initiation algorithms to allow faster or same-day initiation [11][12][13][14][15][16][17] improves ART uptake and outcomes [18]. Most of these studies were done under trial conditions or in a few selected sites, however, leaving questions about generalizability to routine care.…”

Stumbling Blocks at the Clinic: Experiences of Seeking HIV Treatment and Care in South Africa

“…Within the context of overcrowded clinics, the number of clinic visits required is a barrier to ART initiation that needs to be removed or reduced. Same-day ART initiation [22, 35] and more efficient models for patient ART preparation [36] could be effective. Recent policy and service delivery guidelines for fast tracked initiation counselling in South Africa should be implemented by clinics as quickly as possible [37].…”

Rapid initiation of antiretroviral therapy for people living with HIV

“…PLWH previously attended HIV services several times for counselling and medical evaluation before starting treatment. Expediting ART initiation could potentially lead to earlier viral suppression in the medium‐ and long‐term through improved uptake and adherence to ART as well as through improved retention in care (Hoenigl 2016; Pilcher 2017; Wilkinson 2015); what could result in lower overall mortality. Recent guidelines now advocate for ART initiation within seven days of HIV diagnosis (WHO 2018), with same‐day initiation for those patients who feel ready, but ART initiation should be deferred if tuberculosis or cryptococcal meningitis is suspected or confirmed, to avoid paradoxical worsening of the existing infection which can be fatal (Ford 2018; WHO 2018).…”