Implementing universal HIV treatment in a high HIV prevalence and rural South African setting - Field experiences and recommendations of health care providers.

Melanie Plazy,Janet Seeley,Delphine Perriat,François Dabis,Dumile Gumede,Joanna Orne-Gliemann,Sylvie Boyer,Deenan Pillay,Ruanne V Barnabas

doi:10.1371/journal.pone.0186883

Abstract

BackgroundWe aimed to describe the field experiences and recommendations of clinic-based health care providers (HCP) regarding the implementation of universal antiretroviral therapy (ART) in rural KwaZulu-Natal, South Africa.MethodsIn Hlabisa sub-district, the local HIV programme of the Department of Health (DoH) is decentralized in 18 clinics, where ART was offered at a CD4 count ≤500 cells/μL from January 2015 to September 2016. Within the ANRS 12249 TasP trial, implemented in part of the sub-district, universal ART (no eligibility criteria) was offered in 11 mobile clinics between March 2012 and June 2016. A cross-sectional qualitative survey was conducted in April–July 2016 among clinic-based nurses and counsellors providing HIV care in the DoH and TasP trial clinics. In total, 13 individual interviews and two focus groups discussions (including 6 and 7 participants) were conducted, audio-recorded, transcribed, and thematically analyzed.ResultsAll HCPs reported an overall good experience of delivering ART early in the course of HIV infection, with most patients willing to initiate ART before being symptomatic. Yet, HCPs underlined that not feeling sick could challenge early ART initiation and adherence, and thus highlighted the need to take time for counselling as an important component to achieve universal ART. HCPs also foresaw logistical challenges of universal ART, and were especially concerned about increasing workload and ART shortage. HCPs finally recommended the need to strengthen the existing model of care to facilitate access to ART, e.g., community-based and integrated HIV services.ConclusionsThe provision of universal ART is feasible and acceptable according to HCPs in this rural South-African area. However their experiences suggest that universal ART, and more generally the 90-90-90 UNAIDS targets, will be difficult to achieve without the implementation of new models of health service delivery.

Highlights

It is well known that health care providers (HCP) are key actors in the effectiveness of health services, especially regarding HIV care [1, 2]
The provision of universal antiretroviral therapy (ART) is feasible and acceptable according to HCPs in this rural South-African area
Their experiences suggest that universal ART, and more generally the 90-90-90 UNAIDS targets, will be difficult to achieve without the implementation of new models of health service delivery

Summary

Introduction

It is well known that health care providers (HCP) are key actors in the effectiveness of health services, especially regarding HIV care [1, 2]. They are in particular responsible for the technical quality of care (services must be performed according to pre-defined medical standards) and the service quality (how services respond to patients’ expectations and cultural values) [3]. We aimed to describe the field experiences and recommendations of clinic-based health care providers (HCP) regarding the implementation of universal antiretroviral therapy (ART) in rural KwaZulu-Natal, South Africa.

Objectives

Methods

Results

Conclusion