Search

Ending AIDS by 2030 would depend on how successful health systems are in linking people living with HIV (PLHIV) into care. The World Health Organization recommended the ‘Universal Test-and-Treat’ (UTT) strategy – initiating all individuals testing positive on antiretroviral therapy (ART) irrespective of their CD4 count and clinical staging. This study aimed to explore the enablers and barriers to linkage to HIV care among adults with a new HIV diagnosis in a high-HIV prevalent rural district in South Africa. A qualitative study was undertaken to explore patients’ perceptions of enablers and barriers of linkage-to-care, using a life-story narration and dialogue approach. In-depth interviews were conducted with 38 HIV-positive participants sampled from a cohort of 1194 HIV positive patients recruited from December 2017 to June 2018. Participants were selected based on whether they had linked to care or not within 3 months of positive HIV diagnosis. Interviews were thematically analysed using a general inductive approach. Of the 38 participants, 22 (58%) linked to care within three months of HIV-positive diagnosis. Factors which facilitated or inhibited linkage-to-care were found at individual, family, community, as well as the health systems levels. Enablers included a positive HIV testing experience, and assistance from the fieldwork team. Support from family, friends, as well as prior community-based education about HIV and ART were also noted. Individual factors such as acceptance of HIV status, previous exposure to PLHIV, and fear of HIV progressing, were identified. Barriers to linkage included, denial of HIV status, dislike of taking pills, and preference for alternative medicine. Negative experience with counselling and health systems inefficiency were also noted as barriers. Perceived stigma and socio-economic factors, such as lack of food or money to visit the clinic were other barriers. Community-based and health system level interventions would need to focus on clinic readiness in providing patients with necessary and effective health services such as proper and adequate counselling. This could increase the number of patients who link to care. Finally, interventions to improve linkage-to-care should consider a holistic approach, including training health care providers, community outreach and the provision of psychological, social, and financial support.

Background South Africa had an estimated 7.5 million people living with HIV (PLHIV), accounting for approximately 20% of the 38.4 million PLHIV globally in 2021. In 2015, the World Health Organization recommended the universal test and treat (UTT) intervention which was implemented in South Africa in September 2016. Evidence shows that UTT implementation faces challenges in terms of human resources capacity or infrastructure. We aim to explore healthcare providers (HCPs)’ perspectives on the implementation of the UTT strategy in uThukela District Municipality in KwaZulu-Natal province. Methods A qualitative study was conducted with one hundred and sixty-one (161) healthcare providers (HCPs) within 18 healthcare facilities in three subdistricts, comprising of Managers, Nurses, and Lay workers. HCPs were interviewed using an open ended-survey questions to explore their perceptions providing HIV care under the UTT strategy. All interviews were thematically analysed using both inductive and deductive approaches. Results Of the 161 participants (142 female and 19 male), 158 (98%) worked at the facility level, of which 82 (51%) were nurses, and 20 (12.5%) were managers (facility managers and PHC manager/supervisors). Despite a general acceptance of the UTT policy implementation, HCPs expressed challenges such as increased patient defaulter rates, increased work overload, caused by the increased number of service users, and physiological and psychological impacts. The surge in the workload under conditions of inadequate systems’ capacity and human resources, gave rise to a greater burden on HCPs in this study. However, increased life expectancy, good quality of life, and immediate treatment initiation were identified as perceived positive outcomes of UTT on service users. Perceived influence of UTT on the health system included, increased number of patients initiated, decreased burden on the system, meeting the 90-90-90 targets, and financial aspects. Conclusion Health system strengthening such as providing more systems’ capacity for expected increase in workload, proper training and retraining of HCPs with new policies in the management of patient readiness for lifelong ART journey, and ensuring availability of medicines, may reduce strain on HCPs, thus improving the delivery of the comprehensive UTT services to PLHIV.

Introduction: HIV care, linkage, and retention are key weaknesses in South Africa’s national antiretroviral therapy (ART) program, with the greatest loss of patients in the HIV treatment pathway occurring before ART initiation. Very few studies have investigated the proportion of people newly diagnosed with HIV linked-to and retained-in-care in the ‘Universal Test-and-Treat’ era. This study investigated linkage-to and early-retention-in-care (LTRIC) rates among adults newly diagnosed with HIV in a high-HIV prevalent rural district. Methods: We conducted an observational prospective cohort study from December 2017 to August 2019 to investigate LTRIC rates for adults with a new HIV diagnosis in uThukela district, South Africa. Patient-level survey and clinical data were collected using a one-stage-cluster design from 18 healthcare facilities and triangulated between HIV and laboratory databases and registered deaths from Department of Home Affairs. We used Chi-square tests to assess associations between categorical variables, and results were stratified by HIV status, sex, and age. Confidence intervals (CI) and p-value of £0.05 were reported to consider statistical significance. Results: Of the 5,637 participants recruited from December 2017 to June 2018, 21.2% [1,194/5,637; CI: 15.8-26.5] had confirmed HIV. Of the HIV-positive participants, 70.9% were women, and 46.5% were aged 25–34 years. Although 82.7% of participants (987/1,194) were linked-to-care within 3 months, only 46.1% (551/1,194; CI: 31.0-61.3) remained-in-care 12 months after initiating ART and 5.2% (62/1,194; CI: 4.0-6.6) were deceased. While a significantly higher proportion of men were linked-to-care at 3 months compared to women [85.1% (292/343); CI: 80.4-88.9 vs. 81.7 (695/851); CI: 75.0-86.9, p=0.03], a significantly proportion of women [49.5% (419/847); CI: 34.3-64.7] remained-in-care at 12 months than men [38.0% (132/347); CI: 24.6-53.6, p=0.01). Nearly half of the participants retained-in-care were aged 35–49 years (49.1%). Post-secondary education (p=0.05) and child support grants (p=0.03) were independently significantly associated with retention. Conclusion: We found high initial linkage-to-care rates, but less than 50% of participants remained-in-care at 12 months. Significant effort is required to retain PLHIV in care, especially during the first year after ART initiation. Our findings suggest that interventions could target women aged 18–34 years; more research is needed to understand barriers to LTRIC for men.