Abstract
BackgroundThe recently increased access to antiretroviral therapy (ART) in South Africa has placed additional strain on human and infrastructure resources of the public health sector. Capacity from private-sector General Practitioners (GPs) could be leveraged to ease the current burden on the public health sector.MethodsWe conducted a retrospective record review of routine electronic medical record data on a systematic sample of HIV-infected adults (≥18 years old) initiated on ART at a tertiary hospital outpatient HIV clinic in Johannesburg, South Africa and down-referred to private-GPs for continued care after stabilization on ART. We compared these patients (“GP down-referred”) to a control-cohort who remained at the referring site (“Clinic A”) and patients from a regional hospital outpatient HIV clinic not offering down-referral to GPs (“Clinic B”). Study outcomes assessed are viral load suppression (VL < 50 copies/ml) and attrition from care (all-cause-mortality or > 90-days late for a last-scheduled visit) by 12 months of follow-up following down-referral or eligibility.ResultsA total of 3685 patients, comprising 373 (10.1%) GP down-referred, 2599 (70.5%) clinic A controls, and 713 (19.4%) clinic B controls were included in the analysis. Overall, 1535 patients (53.3%) had a suppressed viral load. A higher portion of GP down-referred patients had a suppressed viral load compared to clinic A and B patients (65.7% vs 49.1% vs 58.9%). After adjusting for demographic and baseline clinical covariates, we found no difference in viral load suppression between GP down-referred and control patients (adjusted relative risk [aRR] for clinic A vs GP down-referred 1.0; 95% CI: 0.9–1.1), (aRR for clinic B vs GP down-referred 1.0; 95% CI: 0.9–1.2).Clinic B controls experienced the highest attrition compared to GP down-referred and clinic A controls (33.2% vs 11.3% vs 5.9%) and had a higher risk of attrition compared to GP down-referred patients (adjusted hazard ratio [aHR] 4.2; 95% CI: 2.8–6.5), whereas clinic B controls had a lower risk of attrition (aHR 0.5; 95% CI: 0.3–0.7).Conclusions and recommendationsOur results show that private-GPs can contribute to caring for stabilized public sector HIV patients on life-long ART. However, they require special efforts to improve retention in care.
Highlights
The recently increased access to antiretroviral therapy (ART) in South Africa has placed additional strain on human and infrastructure resources of the public health sector
After adjusting for demographic and baseline clinical baseline covariates, there was no difference in 12-month viral load suppression between general practitioner (GP) down-referred and control patients
After adjusting for baseline factors, clinic B controls had over four times the risk of attrition from care compared to GP down-referred patients
Summary
The recently increased access to antiretroviral therapy (ART) in South Africa has placed additional strain on human and infrastructure resources of the public health sector. In 2015 South Africa adopted the UNAIDS 90–90-90 targets aiming to: diagnose 90% of all people living with HIV; enrol 90% of diagnosed patients on sustained ART; and ensure that 90% of patients on ART achieve viral suppression [4] To achieve these targets, in September 2016, South Africa further expanded ART access to include all persons diagnosed with HIV regardless of baseline CD4 count [5]. In September 2016, South Africa further expanded ART access to include all persons diagnosed with HIV regardless of baseline CD4 count [5] This universal-test-and-treat (UTT) strategy aims to increase early ART initiation to reduce morbidity and mortality further, and hopefully reduce HIV transmission rates [5]. The increased access to ART from these scale-up efforts is likely to place additional strain on the already burdened public health sector
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