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

Maughan-Brown, Brendan; Kuo, Caroline; Galárraga, Omar; Pk, Smith; Lurie, Mark N.; Bekker, Linda‐Gail; Harrison, Abigail

doi:10.1007/s10461-017-1877-4

Cited by 41 publications

(32 citation statements)

References 33 publications

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“…HIVST presents a potential way of circumventing these issues by allowing people to test alone at home, but concerns remain regarding the provision of adequate pre-and post-test counselling, linkage to care, and proper test conduct [5,12]. Furthermore, with South Africa's 2016 policy move introducing a "treatment for all approach" [25], improvements in the overall efficiency and quality of HIV care services is crucial to its sustainability [26].…”

Section: Discussionmentioning

confidence: 99%

Alone But Supported: A Qualitative Study of an HIV Self-testing App in an Observational Cohort Study in South Africa

et al. 2019

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HIV self-testing has the potential to improve test access and uptake, but concerns remain regarding counselling and support during and after HIV self-testing. We investigated an oral HIV self-testing strategy together with a mobile phone/tablet application to see if and how it provided counselling and support, and how it might impact test access. This ethnographic study was nested within an ongoing observational cohort study in Cape Town, South Africa. Qualitative data was collected from study participants and study staff using 33 semi-structured interviews, one focus group discussion, and observation notes. The app provided information and guidance while also addressing privacy concerns. The flexibility and support provided by the strategy gave participants more control in choosing whom they included during testing. Accessibility concerns included smartphone access and usability issues for older and rural users. The adaptable access and support of this strategy could aid in expanding test access in South Africa. ResumenEl autotest del VIH puede mejorar su acceso y uso, pero, existe inquietud sobre el asesoramiento y apoyo al paciente durante y después del autotest. Investigamos una estrategia de autotest oral con una aplicación para teléfono/tableta para observar cómo proporcionaría asesoramiento y apoyo, e influenciaría el acceso al test. Este estudio etnográfico fue anidado en un estudio de cohorte observacional en curso en Ciudad del Cabo, Sudáfrica. Recogimos datos cualitativos de participantes y personal del estudio empleando 33 entrevistas semiestructuradas, una discusión de grupo focal, y apuntes de observación. La aplicación proporcionó información y orientación, abordando inquietudes sobre privacidad. La flexibilidad y apoyo al paciente proporcionaron a los participantes más control sobre quién involucraban en el test. Problemas de accesibilidad incluyeron acceso y uso de Smartphone en usuarios mayores y residentes rurales. El acceso adaptable y apoyo de esta estrategia podría ayudar a expandir el acceso al test en Sudáfrica.Publisher's Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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Section: Discussionmentioning

confidence: 99%

Alone But Supported: A Qualitative Study of an HIV Self-testing App in an Observational Cohort Study in South Africa

et al. 2019

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“…For example, our finding that a substantial proportion (over a third) of participants linked to care, but did not start treatment within 3 months, aligns with qualitative evidence indicating significant clinicrelated barriers to ART initiation. 28 These findings suggest that models of ART initiation that are patient centered, such as same-day ART initiation and models with more efficient ART preparation, 29,50,51 may improve ART uptake.…”

Section: Discussionmentioning

confidence: 97%

“…Study participants typically had to make 4-6 clinic visits before ART initiation, and several participants in the incentive group reported giving up on the process. 28 These qualitative findings raise the possibility that the incentive amount was not large enough to overcome the high costs associated with ART initiation. In other words, the incentive may have been too small to provide adequate motivation for participants to complete the onerous ART initiation process.…”

Section: Discussionmentioning

confidence: 99%

“…[25][26][27] In South Africa, individual impediments to early ART access have historically been compounded by the requirement of patients to make multiple, and time-consuming, clinic visits to initiate ART, with patients typically making 4-6 visits before receiving medication. 28,29 The process included HIV diagnosis, ART eligibility screening, baseline blood tests and physical examinations, and extensive pre-ART counseling that aimed to improve long-term adherence. 30,31 The high costs associated with ART initiation help explain why some individuals perceive ART as more of an immediate burden than a benefit and consequently delay treatment.…”

Section: Introductionmentioning

confidence: 99%

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A Conditional Economic Incentive Fails to Improve Linkage to Care and Antiretroviral Therapy Initiation Among HIV-Positive Adults in Cape Town, South Africa

Maughan-Brown

Kuo

et al. 2018

AIDS Patient Care and STDs

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Interventions to improve antiretroviral therapy (ART) access are urgently needed to maximize the multiple benefits from ART. This pilot study examined the effect of a conditional economic incentive on linkage to care and uptake of treatment following ART referral by a mobile health clinic. Between April 2015 and May 2016, 86 individuals (≥18 years old) referred for ART in a resource-limited setting were randomized (1:1) to a control group or to an incentive: R300 cash (∼$23, or 3.5 days minimum wage in the domestic worker sector), conditional upon starting ART within 3 months. Outcome data were obtained from clinic records. The incentive effects on linkage to care (first clinic visit within 3 months) and ART initiation (treatment uptake within 3 months) were assessed using logistic regression. Overall, 67% linked to care and 42% initiated ART within 3 months after referral. No significant differences were found between the incentive and non-incentive group in terms of linkage to care [adjusted odds ratio (aOR): 0.70, 95% confidence interval (CI): 0.26-1.91] and initiation of ART (aOR: 0.67, 95% CI: 0.26-1.78). Ordinary least-squares regression analysis showed that incentivized individuals linked to care in fewer days (-7.9, 95% CI: -18.09 to 2.26) and started treatment in fewer days (-7.3, 95% CI: -27.01 to 12.38), but neither result was statistically significant. Our findings demonstrate poor treatment uptake by both the intervention and control participants and further highlight the challenge in achieving universal early treatment access. Further research is required to understand how economic incentives, which have been shown to have many benefits, can be applied to improve linkage to HIV care and treatment.

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“…In many countries, standard procedures for initiation of HIV-infected patients onto treatment remain slow and cumbersome, deterring some patients from starting ART entirely and leading to long delays for others. Anecdotal field reports suggest that there has been some recent improvement in accelerating ART initiation, but multiple pre-initiation visits, long waiting times, stock-outs of supplies, staff absences, and poor communication between staff and patients remain common [ 5 – 7 ].…”

Section: Introductionmentioning

confidence: 99%

Improved simplified clinical algorithm for identifying patients eligible for immediate initiation of antiretroviral therapy for HIV (SLATE II): protocol for a randomized evaluation

Rosen

Maskew

Brennan

et al. 2018

Trials

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BackgroundThe World Health Organization recommends rapid (≤ 7 days) or same-day initiation of antiretroviral treatment (ART) for HIV-positive patients. South Africa adopted this recommendation in 2017, but multiple clinic visits, long waiting times, and delays for laboratory tests remain common. Streamlined approaches to same-day initiation that allow the majority of patients to start ART immediately, while ensuring that patients who do require additional services receive them, are needed to achieve national and international treatment program goals.Methods/DesignThe SLATE II (Simplified Algorithm for Treatment Eligibility) study is an individually randomized evaluation of a clinical algorithm to reliably determine a patient’s eligibility for immediate ART initiation without waiting for laboratory results or additional clinic visits. It differs from the earlier SLATE I study in management of patients with symptoms of tuberculosis (under SLATE II these patients may be started on ART immediately) and other criteria for immediate initiation. SLATE II will randomize (1:1) 600 adult, HIV-positive patients who present for HIV testing or care and are not yet on ART in South Africa. Patients randomized to the standard arm will receive standard-of-care ART initiation from clinic staff. Patients randomized to the intervention arm will be administered a symptom report, medical history, brief physical exam, and readiness assessment. Symptomatic patients will also have a tuberculosis (TB) module with lipoarabinomannan antigen of mycobacteria test. Patients who have satisfactory results for all four components will be dispensed antiretrovirals (ARVs) immediately, at the same clinic visit. Patients who have any negative results will be referred for further investigation, care, counseling, tests, or other services prior to being dispensed ARVs. Follow-up will be by passive medical record review. The primary outcomes will be ART initiation in ≤ 7 days and retention in care 8 months after study enrollment.DiscussionSLATE II improves upon the SLATE I study by reducing the number of reasons for delaying ART initiation and allowing more patients with TB symptoms to start ART on the day of diagnosis. If successful, SLATE II will provide a simple and streamlined approach that can readily be adopted in other settings without investment in additional technology.Trial registrationClinicalTrials.gov, NCT03315013. Registered on 19 October 2017.Electronic supplementary materialThe online version of this article (10.1186/s13063-018-2928-5) contains supplementary material, which is available to authorized users.

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

Cited by 41 publications

References 33 publications

Alone But Supported: A Qualitative Study of an HIV Self-testing App in an Observational Cohort Study in South Africa

Alone But Supported: A Qualitative Study of an HIV Self-testing App in an Observational Cohort Study in South Africa

A Conditional Economic Incentive Fails to Improve Linkage to Care and Antiretroviral Therapy Initiation Among HIV-Positive Adults in Cape Town, South Africa

Improved simplified clinical algorithm for identifying patients eligible for immediate initiation of antiretroviral therapy for HIV (SLATE II): protocol for a randomized evaluation

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