A novel HIV treatment model using private practitioners in South Africa

Abstract

Objectives The extent of the HIV epidemic in South Africa may render the public sector capacity inadequate to manage all patients requiring antiretroviral therapy (ART). Private practitioners are an underutilised resource that could be utilized to ease this challenge. Methods We developed a model of care using 72 private practitioners in five provinces in urban and rural areas of South Africa with centralised clinical support, training, pharmacy control and data management. We describe the programme, its quality control measures and patient outcomes using a cohort analysis. Results Between January 2005 and December 2008, 9,102 individuals were started on ART, 63% female, mean age 35 years, median viral load 50,655 copies/ml and median baseline CD4 count 123 cells/μl. Retention (alive and in care) in those who started on ART after 12 months was 63% (5,743/9,102) in the 2005 cohort and did not change by calendar year. After 36 months, retention was 50% and 59%, for those enrolled in 2005 and 2006 respectively. The percentage virally suppressed remained similar over the cohorts at 6 months, 82% vs. 84%, 84% and 85% from 2005 - 2008, p=0.66; but improved slightly at 12 months, 78% vs. 83%, 83% and 84% from 2005 - 2008, p=0.05. Conclusions The results show that a well-managed private practitioner-based model can achieve comparable results to public service programmes, although long-term retention needs further evaluation. This model of ART delivery can be used to expand access to ART in areas where the public sector is unable to meet the demand.

Retention and mortality outcomes from a community‐supported public–private HIV treatment programme in Myanmar

“…Studies among private GPs in urban and rural South Africa found relatively high rates of loss to follow-up, ranging from 15% at 12 or 24 months [23,24] to 50% at 36 months [25]. In Myanmar, other providers of ART have also reported higher loss to follow-up rates of rates ranging from 6.5 to 7% [26,27].…”

“…In this study, viral load was not routinely available due to associated costs, which is a limitation of the extent to which conclusions can be drawn regarding the quality of care outcomes, especially in light of recent recommendations for routine viral load monitoring [5]. However, studies conducted among private sector practitioners where viral load testing is routinely available have reported viral suppression rates of up to 82% at 36 weeks among retained patients [25]. Although generalizability of the findings in this study may be limited by context specific factors such as heavy involvement of community-based support, results from this study contribute to the literature describing outcomes of ART from the private GPs and indicate potential for wider engagement of the private sector and community support towards achieving universal access to decentralized ART.…”

Comparison of Tenofovir, Zidovudine, or Stavudine as Part of First-Line Antiretroviral Therapy in a Resource-Limited-Setting: A Cohort Study

“…The study population consisted of HIV-infected patients enrolled in community or workplace HIV care programs applying standardized treatment and monitoring approaches and overseen by a single HIV management organization [7], [8]. The workplace program used a regimen of AZT, lamivudine (3TC), and efavirenz (EFV) or nevirapine (NVP) until mid-2007, when there was a shift to TDF, 3TC or emtricitabine (FTC), and EFV or NVP.…”

Mortality Associated With Delays Between Clinic Entry and ART Initiation in Resource-Limited Settings

“…These cohorts were (i) a study of isoniazid preventive therapy among mine workers with HIV conducted prior to the availability of ART, 23 (ii) data from a large cohort of patients who were provided free HIV care services through a network of community general practitioner HIV providers, 24 and (iii) data from a centrally managed ART program in multiple workplace and community clinics. 25 Isoniazid preventive study patient-level data were used to calculate CD4 count state transition probabilities, the community general practitioner cohort (the pre-ART cohort) was used to calculate pre-ART mortality, and the ART program cohort (the ART cohort) was used to calculate on-ART mortality.…”