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Many maternal and neonatal deaths can be avoided if quality healthcare is provided. To this end, the South African National Department of Health implemented a quality improvement (QI) programme (2018–2022) to improve maternal and neonatal health services in 21 public health facilities. This study sought to identify good practices aimed at improving QI teams' performance by identifying optimal facility-level contextual factors and implementation processes. We purposively selected 14 facilities of the 21 facilities for a longitudinal qualitative process evaluation. We interviewed 17 team leaders, 47 members, and five QI advisors who provided technical support to the teams. The data were analysed using framework analysis. We choose the Consolidated Framework for Implementation Research as framework given that it explicates contexts and processes that shape programme implementation. Six quality improvement teams were assessed as well-performing, and eight as less well-performing. This research conceptualises a 'life course lens' for setting up and managing a QI team. We identified eight good practices, six related to implementation processes, and two contextual variables that will optimise team performance. The two most impactful practices to improve the performance of a QI team were (i) selecting healthcare workers with quality improvement-specific characteristics, and (ii) appointing advisors whose interpersonal skills match their technical quality improvement competencies. [ABSTRACT FROM AUTHOR]

: Introduction: The proven effectiveness of injectable cabotegravir (CAB‐LA) is higher than that of any other HIV prevention intervention ever trialled or implemented, surpassing medical male circumcision, condoms and combination antiretroviral treatment. Based on our own analyses and experience with the South African oral pre‐exposure prophylaxis (PrEP) programme, we review the supply and demand side factors that would need to be in place for a successful rollout of CAB‐LA, and delineate lessons for the launch of other long‐acting and extended delivery (LAED) antiretroviral drugs. Discussion: On the supply side, CAB‐LA will have to be offered at a price that makes the drug affordable and cost‐effective to low‐ and middle‐income countries, especially those with high HIV prevalence. An important factor in lowering prices is a guaranteed market volume, which in turn necessitates the involvement of large funders, such as PEPFAR and the Global Fund, and a fairly rapid scale‐up of the drug. Such a scale‐up would have to involve speedy regulatory approval and WHO pre‐qualification, swift integration of CAB‐LA into national guidelines and planning for large enough manufacturing capacity, including the enabling of local manufacture. On the demand side, existing demand for HIV prevention products has to be harnessed and additional demand created, which will be aided by designing CAB‐LA programmes at the primary healthcare or community level, and involving non‐traditional outlets, such as private pharmacies and doctors’ practices. Conclusions: CAB‐LA could be the game changer for HIV prevention that we have been hoping for, and serve as a useful pilot for other LAEDs. A successful rollout would involve building markets of a guaranteed size; lowering the drug's price to a level possibly below the cost of production, while also lowering the cost of production altogether; harnessing, creating and sustaining demand for the product over the long term, wherever possible, in national programmes rather than single demonstration sites; and establishing and maintaining manufacturing capacity and supply chains. For this, all parties have to work together—including originator and generic manufacturers, donor organizations and other large funders, and the governments of low‐ and middle‐income countries, in particular those with high HIV prevalence., INTRODUCTION Could injectable cabotegravir (CAB‐LA) be the game changer for HIV prevention that the world has been waiting for—especially low‐ and middle‐income countries (LMICs) with high HIV prevalence? And what [...]

Introduction: Until COVID-19, tuberculosis (TB) was the leading infectious disease killer globally, disproportionally affecting people with HIV. The COVID-19 pandemic is threatening the gains made in the fight against both diseases. Discussion: Although crucial guidance has been released on how to maintain TB and HIV services during the pandemic, it is acknowledged that what was considered normal service pre-pandemic needs to improve to ensure that we rebuild person-centred, inclusive and quality healthcare services. The threat that the pandemic may reverse gains in the response to TB and HIV may be turned into an opportunity by pivoting to using proven differentiated service delivery approaches and innovative technologies that can be used to maintain care during the pandemic and accelerate improved service delivery in the long term. Models of care should be convenient, supportive and sufficiently differentiated to avoid burdensome clinic visits for medication pick-ups or directly observed treatments. Additionally, the pandemic has highlighted the chronic and short-sighted lack of investment in health systems and the need to prioritize research and development to close the gaps in TB diagnosis, treatment and prevention, especially for children and people with HIV. Most importantly, TB-affected communities and civil society must be supported to lead the planning, implementation and monitoring of TB and HIV services, especially in the time of COVID-19 where services have been disrupted, and to report on legal, policy and gender-related barriers to access experienced by affected people. This will help to ensure that TB services are held accountable by affected communities for delivering equitable access to quality, affordable and non-discriminatory services during and beyond the pandemic. Conclusions: Successfully reaching the related targets of ending TB and AIDS as public health threats by 2030 requires rebuilding of stronger, more inclusive health systems by advancing equitable access to quality TB services, including for people with HIV, both during and after the COVID-19 pandemic. Moreover, services must be rights-based, community-led and community-based, to ensure that no one is left behind. Keywords: tuberculosis; HIV; COVID-19; differentiated service delivery; innovation; integration; stigma; people affected by TB, 1 | INTRODUCTION Until COVID-19, tuberculosis (TB) was the leading infectious disease killer globally, including among people with HIV [1], who are disproportionally affected by TB [2,3]. In 2019, at [...]

Introduction: In response to suboptimal adherence and retention, South Africa's National Department of Health developed and implemented National Adherence Guidelines for Chronic Diseases. We evaluated the effect of a package of adherence interventions beginning in January 2016 and report on the impact of Fast-Track Treatment Initiation Counselling (FTIC) on ART initiation, adherence and retention. Methods: We conducted a cluster-randomized mixed-methods evaluation in 4 provinces at 12 intervention sites which implemented FTIC and 12 control facilities providing standard of care. Follow-up was by passive surveillance using clinical records. We included data on subjects eligible for FTIC between 08 Jan 2016 and 07 December 2016. We adjusted for pre-intervention differences using difference-in-differences (DiD) analyses controlling for site-level clustering. Results: We enrolled 362 intervention and 368 control arm patients. Thirty-day ART initiation was 83% in the intervention and 82% in the control arm (RD 0.5%; 95% CI: -5.0% to 6.0%). After adjusting for baseline ART initiation differences and covariates using DiD we found a 6% increase in ART initiation associated with FTIC (RD 6.3%; 95% CI: -0.6% to 13.3%). We found a small decrease in viral suppression within 18 months (RD -2.8%; 95% CI: -9.8% to 4.2%) with no difference after adjustment (RD: -1.9%; 95% CI: -9.1% to 5.4%) or when considering only those with a viral load recorded (84% intervention vs. 86% control). We found reduced crude 6-month retention in intervention sites (RD -7.2%; 95% CI: -14.0% to -0.4%). However, differences attenuated by 12 months (RD: -3.6%; 95% CI: -11.1% to 3.9%). Qualitative data showed FTIC counselling was perceived as beneficial by patients and providers. Conclusions: We saw a short-term ART-initiation benefit to FTIC (particularly in districts where initiation prior to intervention was lower), with no reductions but also no improvement in longer-term retention and viral suppression. This may be due to lack of fidelity to implementation and delivery of those components that support retention and adherence. FTIC must continue to be implemented alongside other interventions to achieve the 90-90-90 cascade and fidelity to post-initiation counselling sessions must be monitored to determine impact on longer-term outcomes. Understanding the cost-benefit and role of FTIC may then be warranted. Keywords: adherence; ARV; counselling; differentiated care; South Africa; viral load, 1 | INTRODUCTION Extensive data from sub-Saharan Africa since large-scale antiretroviral therapy (ART) rollout began shows suboptimal retention in HIV care [1-6]. A particular point of concern is the period [...]

: Introduction: In 2014, the South African government adopted a differentiated service delivery (DSD) model in its “National Adherence Guidelines for Chronic Diseases (HIV, TB and NCDs)” (AGL) to strengthen the HIV care cascade. We describe the barriers and facilitators of the AGL implementation as experienced by various stakeholders in eight intervention and control sites across four districts. Methods: Embedded within a cluster‐randomized evaluation of the AGL, we conducted 48 in‐depth interviews (IDIs) with healthcare providers, 16 IDIs with Department of Health and implementing partners and 24 focus group discussions (FGDs) with three HIV patient groups: new, stable and those not stable on treatment or not adhering to care. IDIs were conducted from August 2016 to August 2017; FGDs were conducted in January to February 2017. Content analysis was guided by the Consolidated Framework for Implementation Research. Findings were triangulated among respondent types to elicit barriers and facilitators to implementation. Results: New HIV patients found counselling helpful but intervention respondents reported sub‐optimal counselling and privacy concerns as barriers to initiation. Providers felt insufficiently trained for this intervention and were confused by the simultaneous rollout of the Universal Test and Treat strategy. For stable patients, repeat prescription collection strategies (RPCS) were generally well received. Patients and providers concurred that RPCS reduced congestion and waiting times at clinics. There was confusion though, among providers and implementers, around implementation of RPCS interventions. For patients not stable on treatment, enhanced counselling and tracing patients lost‐to‐follow‐up were perceived as beneficial to adherence behaviours but faced logistical challenges. All providers faced difficulties accessing data and identifying patients in need of tracing. Congestion at clinics and staff attitude were perceived as barriers preventing patients returning to care. Conclusions: Implementation of DSD models at scale is complex but this evaluation identified several positive aspects of AGL implementation. The positive perception of RPCS interventions and challenges managing patients not stable on treatment aligned with results from the larger evaluation. While some implementation challenges may resolve with experience, ensuring providers and implementers have the necessary training, tools and resources to operationalize AGL effectively is critical to the overall success of South Africa’s HIV control strategy., Introduction South Africa has the largest HIV treatment programme in the world, with 4.7 million public sector patients on treatment and a target of 6.1 million patients by end December [...]

Background Differentiated antiretroviral therapy (ART) delivery models, in which patients are provided with care relevant to their current status (e.g., newly initiating, stable on treatment, or unstable on treatment) has become an essential part of patient-centered health systems. In 2015, the South African government implemented Chronic Disease Adherence Guidelines (AGLs), which involved five interventions: Fast Track Initiation Counseling for newly initiating patients, Enhanced Adherence Counseling for patients with an unsuppressed viral load, Early Tracing of patients who miss visits, and Adherence Clubs (ACs) and Decentralized Medication Delivery (DMD) for stable patients. We evaluated two of these interventions in 24 South African facilities: ACs, in which patients meet in groups outside usual clinic procedures and receive medication; and DMD, in which patients pick up their medication outside usual pharmacy queues. Methods and findings We compared those participating in ACs or receiving DMD at intervention sites to those eligible for ACs or DMD at control sites. Outcomes were retention and sustained viral suppression ( Conclusions In this study, we found comparable DMD outcomes versus standard of care at facilities, a benefit for retention of patients in care with ACs, and apparent benefits in terms of retention (for AC patients) and sustained viral suppression (for DMD patients) among men. This suggests the importance of alternative service delivery models for men and of community-based strategies to decongest primary healthcare facilities. Because these strategies also reduce patient inconvenience and decongest clinics, comparable outcomes are a potential success. The cost of all five AGL interventions and possible effects on reducing clinic congestion should be investigated. Clinical Trial registration NCT02536768., Author(s): Matthew P. Fox 1,2,3,*, Sophie Pascoe 3, Amy N. Huber 3, Joshua Murphy 3, Mokgadi Phokojoe 4, Marelize Gorgens 5, Sydney Rosen 1,3, David Wilson 5, Yogan Pillay 4, [...]

Problem The World Health Organization has produced clear guidelines for the prevention of mother-to-child transmission (PMTCT) of the human immunodeficiency virus (HIV). However, ensuring that all PMTCT programme components are implemented to a high quality in all facilities presents challenges. Approach Although South Africa initiated its PMTCT programme in 2002, later than most other countries, political support has increased since 2008. Operational research has received more attention and objective data have been used more effectively. Local setting In 2010, around 30% of all pregnant women in South Africa were HIV-positive and half of all deaths in children younger than 5 years were associated with the virus. Relevant changes Between 2008 and 2011, the estimated proportion of HIV-exposed infants younger than 2 months who underwent routine polymerase chain reaction (PCR) tests to detect early HIV transmission increased from 36.6% to 70.4%. The estimated HIV transmission rate decreased from 9.6% to 2.8%. Population-based surveys in 2010 and 2011 reported transmission rates of 3.5% and 2.7%, respectively. Lessons learnt Critical actions for improving programme outcomes included: ensuring rapid implementation of changes in PMTCT policy at the field level through training and guideline dissemination; ensuring good coordination with technical partners, such as international health agencies and international and local nongovernmental organizations; and making use of data and indicators on all aspects of the PMTCT programme. Enabling health-care staff at primary care facilities to initiate antiretroviral therapy and expanding laboratory services for measuring CD4+ T-cell counts and for PCR testing were also helpful. Probleme LOrganisation mondiale de la Sante a elabore des lignes directrices claires pour la prevention de la transmission mere-enfant (PTME) du virus de l'immunodeficience humaine (VIH). S'assurer que tous les elements du programme de PTME soient mis en ceuvre de maniere qualitative dans tous les etablissements presente cependant des defis. Approche Bien que l'Afrique du Sud ait lance son programme de PTME en 2002, plus tard que la plupart des autres pays, le soutien politique a augmente depuis 2008. La recherche operationnelle a recu davantage d'attention, et les donnees objectives ont ete utilisees plus efficacement. Environnement local En 2010, environ 30% de toutes les femmes enceintes en Afrique du Sud etaient seropositives, et la moitie de tous les deces d'enfants de moins de 5 ans etaient associee au virus. Changements significatifs Entre 2008 et 2011, la proportion estimee de nourrissons de moins de 2 mois exposes au VIH, ayant subi une reaction en chaine par polymerase (PCR) de routine visant a detecter la transmission precoce du VIH, est passee de 36,6% a 70,4%. Le taux estime de transmission du VIH a diminue, passant de 9,6% a 2,8%. Les enquetes basees sur la population en 2010 et 2011 ont signale des taux de transmission de 3,5% et 2,7%, respectivement. Lecons tirees Voici certaines actions essentielles pour ameliorer les resultats du programme: assurer la mise en ceuvre rapide des changements de politique de PTME sur le terrain, grace a la formation et a la diffusion des lignes directrices; assurer une bonne coordination avec les partenaires techniques, comme les agences de sante internationales et locales et les organisations non gouvernementales; et utiliser les donnees et les indicateurs relatifs a tous les aspects du programme de PTME. Il est aussi utile de permettre au personnel soignant des etablissements de soins de sante primaires d'initier un traitement antiretroviral et de developper les services de laboratoire pour les decomptes de cellules CD4+ T et les tests PCR. Situacion La Organizacion Mundial de la Salud ha presentado unas directrices claras para la prevencion de la transmision del virus de la inmunodeficiencia humana (VIH) de la madre al nino. No obstante, habra que superar algunos desafios para asegurar la puesta en marcha de todos los elementos del programa de prevencion a in de alcanzar un nivel de calidad elevado en todas las instalaciones. Enfoque Aunque Sudafrica inicio su programa de prevencion en el ano 2002, mas tarde que la mayoria de los paises, el apoyo politico ha aumentado desde 2008. Se ha prestado mas atencion a las investigaciones operativas y los datos objetivos se han utilizado con mayor eicacia. Marco regional En 2010, alrededor del 30% de las mujeres embarazadas en Sudafrica eran seropositivas, y la mitad de todas las muertes en ninos menores de cinco anos estuvieron asociadas al virus. Cambios importantes Entre los anos 2008 y 2011, la proporcion estimada de ninos menores de dos meses expuestos al VIH que se sometio a las pruebas rutinarias de reaccion en cadena de la polimerasa aumento del 36,6% al 70,4%, y la tasa estimada de transmision del VIH se redujo del 9,6% al 2,8%. Las encuestas de poblacion de los anos 2010 y 2011 reflejaron unas tasas de transmision del 3,5% y el 2,7%, respectivamente Lecciones aprendidas Las actividades fundamentales para mejorar los resultados del programa incluyeron: garantizar la implementacion rapida de los cambios en la politica de prevencion de la transmision a nivel de campo mediante cursos formativos y la difusion de las directrices; garantizar una coordinacion adecuada entre los socios tecnicos, tales como las agencias sanitarias internacionales y las ONG locales e internacionales; y utilizar los datos e indicadores acerca de todos los aspectos del programa de prevencion de la transmision del VIH de la madre al nino. Tambien resulto muy util permitir al personal sanitario de los centros de atencion primaria iniciar terapias antirretrovirales y ampliar los servicios de laboratorio para realizar los recuentos de linfocitos T CD4+ y las pruebas de reaccion en cadena de la polimerasa., Introduction The magnitude of the problem of human immunodeficiency virus (HIV) infection in South Africa is illustrated in Fig. 1, which shows the rise of the HIV pandemic since 1990 [...]

In Africa, resistance to anti-tuberculosis (TB) drugs has been assumed to be low (1). In 2002, the national drug resistance survey showed rates of multidrug-resistant (MDR) TB in South Africa [...]

: Introduction: In 2014, city leaders from around the world endorsed the Paris Declaration on Fast‐Track Cities, pledging to achieve the 2020 and 2030 HIV targets championed by UNAIDS. The City of Johannesburg – one of South Africa's metropolitan municipalities and also a health district – has over 600,000 people living with HIV (PLHIV), more than any other city worldwide. We estimate what it would take in terms of programmatic targets and costs for the City of Johannesburg to meet the Fast‐Track targets, and demonstrate the impact that this would have. Methods: We applied the Optima HIV epidemic and resource allocation model to demographic, epidemiological and behavioural data on 26 sub‐populations in Johannesburg. We used data on programme costs and coverage to produce baseline projections. We calculated how many people must be diagnosed, put onto treatment and maintained with viral suppression to achieve the 2020 and 2030 targets. We also estimated how treatment needs – and therefore fiscal commitments – could be reduced if the treatment targets are combined with primary HIV prevention interventions (voluntary medical male circumcision (VMMC), an expanded condom programme, and comprehensive packages for female sex workers (FSW) and young females). Results: If current programmatic coverage were maintained, Johannesburg could expect 303,000 new infections and 96,000 AIDS‐related deaths between 2017 and 2030 and 769,000 PLHIV by 2030. Achieving the Fast‐Track targets would require an additional 135,000 diagnoses and 232,000 people on treatment by 2020 (an increase in around 80% over 2016 treatment numbers), but would avert 176,000 infections and 56,500 deaths by 2030. Assuming stable ART unit costs, this would require ZAR 29 billion (USD 2.15 billion) in cumulative treatment investments over the 14 years to 2030. Plausible scale‐ups of other proven interventions (VMMC, condom distribution and FSW strategies) could yield additional reductions in new infections (between 4 and 15%), and in overall treatment investment needs. Scaling up VMMC in line with national targets is found to be cost‐effective in the medium term. Conclusions: The scale‐up in testing and treatment programmes over this decade has been rapid, but these efforts must be doubled to reach 2020 targets. Strategic investments in proven interventions will help Johannesburg achieve the treatment targets and be on track to end AIDS by 2030., Introduction In 2014, city leaders from around the world endorsed the Paris Declaration on Fast‐Track Cities, pledging to achieve the 2020 and 2030 HIV targets championed by UNAIDS. The Fast‐Track [...]

South Africa has the highest burden of HIV-associated tuberculosis. Yogan Pillay tells Fiona Fleck how the health Ministry has brought the two programmes and services together. Q: How did you [...]