“DSD in action” interview: Welcome back! Re-engagement in HIV care in South Africa
“The treatment journey on ART is not linear – like for many other chronic diseases – where someone is diagnosed, starts treatment and stays on it continuously for the rest of their lives.”
We spoke to Diana Mokoena, a medical doctor with a diploma in HIV medicine who currently works as District Programme Manager at Anova Health Institute in Johannesburg, South Africa.
Diana, please tell us about your day-to-day work at Anova.
After 12 years as a clinician providing services directly to people living with HIV in primary healthcare clinics in Johannesburg, I joined Anova. I am the Senior Program Implementation lead who analyses data to track our performance against the 95-95-95 targets, identifying any additional support needs from facilities to implement core activities or step up performance and working with department of health managers for implementation of innovative approaches.
What do you want people to know about antiretroviral therapy (ART) continuity and viral suppression in South Africa?
While 92% of people living with HIV in South Africa know their status, significant improvements in retention and viral suppression will be required to reach the global 95-95-95 targets. The treatment journey on ART is not linear – like for many other chronic diseases – where someone is diagnosed, starts treatment and stays on it continuously for the rest of their lives. Many people on ART in South Africa experience interruptions along this journey. There is usually not one factor that causes disengagement; multiple factors act together to reach a tipping point to keep people out of care [1].
What is the role of healthcare providers in keeping clients from disengaging?
We need to be mindful of the way that interactions and issues, even at initial points of contact like testing, can continue to affect care engagement along the entire care cascade. As healthcare workers, we need to accept that clients may continue to face life challenges that make it difficult for them to stay in care; flexible health services delivered with an empathetic attitude can minimize interruptions [2] when “life happens”.
What are the key components of Anova’s work around re-engagement?
In 2019, Anova started the two-part “Welcome Back” campaign in collaboration with the Johannesburg District Health Services to encourage clients to return to care.
The first phase involved healthcare worker training on how to manage clients on ART, including those who need to restart ART. Phase 2 entailed mass media messaging via radio with 34 community and national radio stations about the importance of returning to care with the theme, The Time is Now, Your Health in Your Hands.
What were the main preliminary outcomes of the Welcome back campaign?
A total of 1,142 clients were successfully restarted on ART over the four months of the first phase, higher than the 825 restarts reported prior to the campaign. Mobility, COVID-19 lockdown restrictions, mandatory transfer letters and negative healthcare worker attitudes were reported as the main reasons that clients interrupted treatment, especially when difficult life circumstances made it challenging for them to plan ahead.
What are additional lessons learned that could be useful for other implementers to know?
The first phase supported healthcare workers to improve their approach to clients restarting ART, although some negative attitudes and practices remained [2]. In the second phase, we saw a commitment from healthcare workers to be more welcoming and empathetic to re-engaging clients. A campaign reinforcing this commitment, called “I serve with a smile”, was launched by the Johannesburg Health Chief Director in April 2022. Focus group discussion feedback showed that clients found the radio adverts and interviews encouraging and caring and appreciated the emphasis on taking ownership of their own health.
What were the main challenges and how should they be addressed?
Negative client experiences are a large risk to sustained retention. Because disengagement is driven by both shifting life circumstances and health system barriers, an understanding and flexible service delivery approach will be more supportive of quicker re-engagement and long-term retention. It is difficult to change health staff behaviours permanently. Repeated messaging to healthcare workers about the impact of their own (positive) behaviours on a positive client experience and sustained retention in care is critical.
When looking at facility client flow and other processes to support re-engagement, a prescriptive approach does not work. It is better to give each facility guiding principles and allow them to work out the best fit for their context.
South Africa revised the national adherence guidance in March 2020 and, for the first time, included a differentiated approach to service delivery on re-engagement. How does Anova plan to support implementation?
Supporting the re-engagement journey can never be a one-size-fits-all approach. Stable clients who have difficulty returning for frequent medicine refills would benefit from longer dispensing periods and collection of prepacked refills closer to home. Those who are clinically unwell or experiencing side-effects from ART benefit from clinical interventions such as enhanced adherence counselling.
Anova is working with the IAS on developing job aides for facility-based healthcare workers that will make it easier for them to identify clients who are re-engaging to care and provide the most appropriate service based on an initial clinician assessment. We are optimistic that these will go a long way in facilitating a positive client experience, especially for those who are re-engaging in care, irrespective of their reasons for disengaging in the first place.
References
[1] Genberg B, Shangani S, Sabatino K, et al. Improving engagement in the HIV care cascade: A systematic review of interventions involving people living with HIV/AIDS as peers. AIDS Behaviour.2016;20(10):2452-2463. doi:10.1186/s40945-017-0033
