Health provider perspectives on the implementation of the same-day-ART initiation policy in the Gauteng province of South Africa

Abstract

Background In September 2016, South Africa (SA) began implementing the universal-test-and-treat (UTT) policy in hopes of attaining the UNAIDS 90-90-90 targets by 2020. The SA National Department of Health provided a further directive to initiate antiretroviral therapy (ART) on the day of HIV diagnosis in September 2017. We conducted a qualitative study to determine the progress in implementing UTT and examine health providers' perspectives on the implementation of the same-day initiation (SDI) policy, six months after the policy change. Methods We conducted in-depth interviews with three professional nurses, and four HIV lay counsellors of five primary health clinics in the Gauteng province, between October and December 2017. In September 2018, we also conducted a focus group discussion with ten professional nurses/clinic managers from ten clinic facilities. The interviews and focus groups covered the adoption and implementation of UTT and SDI policies. Interviews were conducted in English, Sotho or Zulu and audio-recorded with participant consent. Audio-recordings were transcribed verbatim, translated to English and analysed thematically using NVivo 11. Results The data indicates inconsistencies across facilities and incongruities between counsellor and nursing provider perspectives regarding the SDI policy implementation. While nurses highlighted the clinical benefits of early ART initiation, they expressed concerns that immediate ART may be overwhelming for some patients, who may be unprepared and likely to disengage from care soon after the initial acceptance of ART. Accordingly, the SDI implementation was slow due to limited patient demand, provider ambivalence to the policy implementations, as well as challenges with infrastructure and human resources. The process for assessing patient readiness was poorly defined by health providers across facilities, inconsistent and counsellor dependent. Providers were also unclear on how to ensure that patients who defer treatment return for ongoing counselling. Conclusions Our results highlight important gaps in the drive to achieve the ART initiation target and demonstrate the need for further engagement with health care providers around the implementation of same-day ART initiation, particularly with regards to infrastructural/capacity needs and the management of patient readiness for lifelong ART on the day of HIV diagnosis. Additionally, there is a need for improved promotion of the SDI provision both in health care settings and in media communications to increase patient demand for early and lifelong ART.

Perceived efficacy of HIV treatment-as-prevention among university students in Johannesburg, South Africa

“…In many countries including South Africa, the prevention benefits of ART are not widely emphasised in public health messaging, school-based HIV curricula, nor HIV counselling. 24 Although stable serodiscordant couples in HIV care are increasingly counselled on TasP, this represents a small fraction of young adults at risk. Consistent with the lack of emphasis on TasP in clinical settings, we found no differences in TasP knowledge by recent use of HIV testing nor by gender (despite gender disparities in care-seeking).…”

Using intervention mapping in motivational interviewing training to improve ART uptake in Gauteng, South Africa

“…The literature review was augmented by in-depth interviews with three clinic managers and four lay HIV counsellors of four primary health clinics in Johannesburg between October and December 2017, exploring current approaches to creating demand for uptake of ART and long-term adherence to ART (demand creation for ART) (Onoya et al, 2018). Interviews were audiorecorded, recordings were transcribed verbatim and analysed thematically using NVivo 11 (Onoya et al, 2018). We found that approaches for ART demand creation were inconsistent and counsellor dependent (Figure 1 in supplementary materials) (Onoya et al, 2018).…”

Retention in care and viral suppression after same‐day ART initiation: One‐year outcomes of the SLATE I and II individually randomized clinical trials in South Africa

“…SLATE I (Simplified Algorithms for Treatment Eligibility I) [3] and SLATE II [4] were designed as simple, clinical algorithms that require no point-of-care laboratory testing and can be used by existing healthcare personnel to distinguish patients who can start ART that day, even if they have mild symptoms of illness, from those who require additional care prior to initiation. While evidence from the SLATE trials [5,6] and others [7,8] demonstrates improved uptake of ART with SDI compared to standard care, concerns remain whether the benefits of SDI can be translated into improved retention once on treatment, or if instead attrition is simply shifted from before to soon after ART initiation, or even made worse by pressure that the expectation of SDI is perceived to place on patients [9,10]. Overall attrition at 8 months was lower in the intervention arm in both trials [5,6], but its timing differed.…”

“…While evidence from the SLATE trials [ 5 , 6 ] and others [ 7 , 8 ] demonstrates improved uptake of ART with SDI compared to standard care, concerns remain whether the benefits of SDI can be translated into improved retention once on treatment, or if instead attrition is simply shifted from before to soon after ART initiation, or even made worse by pressure that the expectation of SDI is perceived to place on patients [ 9 , 10 ]. Overall attrition at 8 months was lower in the intervention arm in both trials [ 5 , 6 ], but its timing differed.…”