From Clinic to Community: Novel Approaches for Decentralizing HIV Service Delivery to Improve Person-Centered Care in South Africa

Abstract

This dissertation was undertaken to investigate novel strategies and diagnostic tools for supporting decentralized health services to increase access to care for people living with HIV (PLHIV). The UNAIDS established the 95-95-95 targets to end the HIV epidemic by 2030, with the goal of having 95% of all PLHIV who are accessing antiretroviral treatment (ART) maintaining viral suppression.1 However, among the approximately 39 million PLHIV worldwide, only half have achieved viral suppression. As overburdened clinics devote limited resources to initiate and monitor millions of PLHIV on ART, there is growing consensus that a blanket model of care is no longer a sustainable strategy for providing life-long HIV services. Diagnostic services are a fundamental component of the HIV cascade of care. However, healthcare providers often rely on conventional laboratory-based testing for viral load (VL) monitoring, which can have lengthy turnaround times that delay clinical decisions, and self-reported adherence, which can be unreliable and biased. In Chapter 1, we present costing estimates for implementation of point-of-care (POC) testing technologies that allow for objective measures of adherence and VL monitoring. Microcosting of POC urine tenofovir testing was conducted within the Simplifying Treatment & Monitoring for HIV (STREAM HIV) study, a randomized implementation trial evaluating POC TFV and HIV VL testing in public health clinic settings in KwaZulu-Natal, South Africa. POC HIV VL testing costs were updated from the Simplifying HIV Treatment and Monitoring (STREAM) pilot study conducted in 2017. Time and motion analysis was also conducted to capture participant and provider time needed for POC TFV testing. These POC technologies have the potential to streamline adherence support and VL monitoring and our findings may inform future policies and budgetary planning for ART monitoring in South Africa and other low- and middle-income countries (LMICs). Compared to other countries, South Africa bears more than double the burden of the HIV epidemic, with almost one in five adults living with HIV and 5.7 million PLHIV on ART in 2022. Differentiated, community-based ART delivery models may reduce the burden on the healthcare system, while also giving clinically stable PLHIV greater access to ART. In Chapter 2 and 3, we explore the Centralized Chronic Medication Dispensing and Distribution (CCMDD) program in South Africa. The CCMDD program is a public-private partnership established over a decade ago that allows patients referred by healthcare workers in government clinics to collect ART refills at private pharmacies or community-based organizations. This program diverts clinically stable patients from overwhelmed clinic settings and facilitates differentiated ART delivery for over 1.7 million people, becoming the largest differentiated care program in the world. In Chapter 2, we investigate the differentiated care CCMDD program in South Africa and determine how participation impacted patient clinical outcomes. We conducted a secondary analysis of cohort data from the STREAM pilot study in Durban, South Africa and estimated the association between routine patient participation in the CCMDD program and clinical outcomes of viral suppression and retention in care. Our analyses in this chapter show the real-world effectiveness of the CCMDD program in maintaining these clinical outcomes compared to standard clinic-based ART provision in South Africa. These findings support national implementation of CCMDD and also highlights the need to increase differentiated care access among vulnerable sub-populations living with HIV and not just among clinically stable patients. In Chapter 3, we delve deeper into gaps in the CCMDD program and employ novel barrier prioritization methods to determine which barriers are the most prevalent, frequent, and critical for ART clients, and thus pivotal to address for successful program implementation. Rapid evidence review was conducted to determine a range of barriers that were then tailored to the KwaZulu-Natal context using in-country expertise. Likert questionnaires were developed using the Theoretical Domains Framework (TDF). Primary data collection was conducted among participants in the Point-of-care HIV Viral Load Testing in a Community Antiretroviral therapy program (PHILA) randomized implementation trial investigating POC VL testing among PLHIV enrolled in the CCMDD program in Durban, South Africa. Our analyses identified key barriers that were frequently experienced and perceived as highly critical for continued participation in the CCMDD program. Identification of these high-priority barriers may provide guidance for future strategies addressing implementation challenges for differentiated ART delivery. Both Chapter 2 and 3 present findings that can be used to support and improve scale-up of the national differentiated care program in South Africa and other LMICs.