The Long Road to Universal Antiretroviral Treatment Coverage in South Africa

Edwin Wouters; Christo Heunis; Joris Michielsen; Francis Baron Van Loon; Herman Meulemans

Future Virology. 2011;6(7):801-812.

Future Perspective

It is evident that a number of steps need to be taken in order to overcome the challenges raised by the current review – certainly, if the South African government aims to initiate ART in all patients with a CD4 cell count below 350 cells/μl blood or even earlier as a means to reduce transmissibility (a preventive public health approach). First, systematic literature analysis suggests that ART services not only have to be integrated into a comprehensive HIV/AIDS prevention and care model (comprising according PMTCT services), but also have to be integrated into other PHC services. In light of the current HIV/TB co-epidemic – in 2007, 73% of all newly diagnosed TB patients in South Africa were estimated to be HIV positive^[110] – standard tuberculosis care should include provider-initiated HIV testing and counseling and ART. In practice, greater service and staff integration can be achieved by rotating staff between programs offered in the ART facility and decentralizing ART services to peripheral facilities currently not providing ART. However, in light of the limited resources, centralization of particular ART service components – for example, ARV drug dispensaries – can also be useful in order to rapidly spread the gains of public sector ART.^[56]

Second, sustained efforts and vigilance will be needed to continue to achieve the current rates of viral suppression, patient retention and survival. In order to avoid drug resistance and loss-to-follow-up, HIV/AIDS care needs to comprise a broad range of support functions. Such comprehensive HIV/AIDS care, treatment and support entails a patient-centered approach with sufficient attention to the social, psychological and economic repercussions of the illness and its treatment, achieved through intensive counseling and support services.

Third, policy makers need to continuously invest in scaling-up ART services. Such funding will not only improve ART program outcomes, but can also develop a sustainable platform for the improved delivery of PHC services in a resource-limited setting where inequity affects the health of the most vulnerable people. However, the development of durable and comprehensive healthcare services necessitates strong leadership, political will and social mobilization.

Fourth, a program of universal access to ART will not only require a new level of performance of the regular health system, but will also require the mobilization of additional human resources. Recent studies indicate that delegation of tasks from doctors to nurses and especially from nurses to lay health workers can lead to the much needed improvements in access, coverage and quality of care.^[88–90] The government is also taking the first steps to providing a legislative platform for downshifting of professional responsibilities to lower cadres of health workers, notably by recently amending the Human Tissues Act to allow lay health workers to administer the 'blood prick' for purposes of HIV testing. Still, there is little evidence that the government is seriously attempting to alleviate the broad spectrum of daunting human resources for health challenges by way of expedited mass professional (especially nurse and social worker) and lay health worker training programs. As long as health and social worker shortages frustrate access to ART, the National Strategic Plan targets will remain untenable.^[111]

Without sufficient attention to the various challenges to a durable and sustainable ART program with universal coverage, it is highly unlikely that the favorable short-term results of the South African ART program can be replicated and maintained during the upcoming decades when South Africa will probably have to rely on ART as its primary therapeutic weapon to combat the HIV/AIDS epidemic.

1 2 3 4 5

Next Section

Financial & competing interests disclosure
The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.
No writing assistance was utilized in the production of this manuscript.

Cite this: The Long Road to Universal Antiretroviral Treatment Coverage in South Africa - Medscape - Jul 01, 2011.

Table 1. Systematic overview of reported on-treatment success rates (virologic suppression) in published longitudinal studies on the outcomes of ART programs in South Africa.
Study	ART program	Success rate (of patients in care)				Definition of success	n^†	Ref.
Study	ART program	6 months	12 months	18 months	24 months	Definition of success	n^†	Ref.
Boulle et al. (2008)	Public community-based ART program (MSF) in Khayelitsha, Western Cape	92.2	89.2	87.1		VL < 400	1218^‡	[18]
Boulle et al. (2010)	Public community-based ART program (MSF) in Khayelitsha, Western Cape		87.6		86.7	VL < 400	3932	[10]
Coetzee et al. (2004)	Public community-based ART program (MSF) in Khayelitsha, Western Cape	89.2	84.2	75.0	69.7	VL < 400	158	[14]
Charalambous et al. (2007)	Workplace-based AIDS care program	75.0	72.0		72.0	VL < 400	999	[16]
Fielding et al. (2008)	Workplace-based AIDS care program		71.5			VL < 400	953	[15]
Ford et al. (2006)	Public community-based ART program (MSF) in Lusikisiki, Eastern Cape		87.0			CD4 > 200	482^§	[19]
			90.0			VL < 400	482
			75.0			CD4 > 200	289^¶
			78.0			VL < 400	289
Hoffmann et al. (2008)	Workplace-based AIDS care program	76.1	74.9			VL < 400	191	[11]
Lawn et al. (2006)	Western Cape public sector ART program in Gugulethu, Cape Town		94.2^#			VL < 400	311	[12]
Lawn et al. (2009)	Western Cape public sector ART program in Gugulethu, Cape Town		90.3		90.5	VL < 400	1426	[13]
Mee et al. (2008)	Workplace-based AIDS care program		88.3			VL < 400	324	[8]
Mutevedzi et al. (2010)	Public primary healthcare system ART program in KwaZulu-Natal		77.0			VL < 25	758	[21]
Orrell et al. (2003)	Multicenter Phase III clinical trial (Cape Town AIDS Cohort)		66.1^#			VL < 400	242	[17]
Schneider et al. (2010)	Western Cape public sector ART program	91.5				VL < 400	712	[20]
	Free State public sector ART program	91.6				VL < 400	138
	Gauteng public sector ART program	88.7				VL < 400	540
Wouters et al. (2009)	Free State public sector ART program	46.1	64.1		76.4	VL < 400 and CD4 > 200	232	[9]
		83.5	84.7		85.6	VL < 400	232
		55.2	69.7		82.7	CD4 > 200	232

^†Number of patients with a VL result after 12 months of ART (Schneider et al. (2010) [20]; 6 months of ART).
^‡Only patients without concurrent antitubercular therapy selected.
^§12 clinics in the Lusikisiki subdistrict of Eastern Cape.
^¶One hospital in the Lusikisiki subdistrict of Eastern Cape.
^#Virological outcome at 48 weeks. ART: Antiretroviral treatment; VL: Viral load.

Comments

Commenting is limited to medical professionals. To comment please Log-in.

Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.