Musa Manganye, Director of HIV/AIDS Treatment, Care and Support at the National Department of Health in South Africa, writes:
Clients’ healthcare experiences in the first months after initiating antiretroviral therapy (ART) set the tone for the rest of their lifelong ART journey and impact related health outcomes, including viral suppression. While using optimized ART regimens is a crucial component of achieving viral suppression, factors related to service delivery play an important role in ensuring continued engagement.
Every time a person living with HIV walks through a clinic door, they reassess their relationship with their HIV service provider and their HIV care management. Variables that influence this decision include: length of the wait; quality of the clinical management; distance travelled to receive a new ART script; lack of clarity around future visit schedules; cost; and time taken off work. Therefore, our actions as healthcare providers contribute significantly to a client’s decision to return to care or not.
To enhance support for clients in their first year on ART, South Africa made important service delivery updates in the “2023 ART Clinical Guidelines for the Management of HIV in Adults, Pregnancy and Breastfeeding, Adolescents, Children, Infants and Neonates”, launched earlier this year. To address suboptimal retention in the first 12 months and suboptimal viral suppression, the guidelines aim to implement optimized regimens and treat as many people as possible with dolutegravir (DTG)-containing regimens, which promote adherence and viral suppression. In addition, the guidelines promote the creation of an enabling environment to support engagement in care and adherence by prioritizing a person-centred approach to service delivery. Clients are empowered with the knowledge and skills they need to manage their care; adherence challenges are identified and addressed earlier; unnecessary clinical or ART refill visits are removed; and the integration of other care needs is strengthened through the alignment of visits.
The guidelines mark an important shift whereby the first viral load (VL) is taken after three months on treatment, which is possible now that clients are initiating DTG-containing regimens. This helps reduce unnecessary facility visits early on for people who are virally suppressed and enables earlier support for people struggling with adherence. From month four, virally suppressed clients receive, at a minimum, three-month multi-month dispensing (3MMD) at the facility. They are eligible for South Africa’s differentiated service delivery (DSD) models, known as repeat prescription collection strategies; these include external pick-up points, facility (fast-lane) pick-up points and adherence clubs (facility-based or community-based). People with possible adherence challenges are identified earlier by an elevated first VL for clinical and adherence management. If clinically well and experiencing challenges with health facility attendance, the person can be provided with 3MMD until their follow-up viral load test three months later.
These new measures are an important contribution to improving the health of people living with HIV and moving South Africa closer to attaining our second and third 95 HIV targets.