Integrated health care model transforms HIV treatment in South Africa

Providing HIV care at local health clinics in South Africa has led to a massive increase in the number of people there receiving vital HIV treatment, according to UBC research.

Indeed, the number of patients receiving HIV therapy in these clinics soared to more than 57,000 from about 1,600 over the four-year period – an increase of nearly 3,500 per cent. Almost 44,000 of these patients had never been on HIV treatment before.

That’s a notable outcome, given that South Africa has among the highest rates of people living with HIV in the world – nearly 10 per cent of the population. The country also has some of the highest HIV and tuberculosis co-infection rates.

In addition, South Africa has the largest HIV-treatment program in the world. In April 2010, a national policy was implemented that stated that all South Africans should be able to access comprehensive HIV treatment and care at the clinic nearest their homes.

Angeli Rawat

Angeli Rawat

Angeli Rawat, a Liu Scholar and recent PhD recipient at UBC’s School of Population and Public Health, has researched the impact of this integrated model. Her dissertation examined the implementation of HIV care at 131 primary health care (PHC) clinics in South Africa’s Free State province, representing a population of 1.5 million, between 2009-2013.

Rawat presents her research at the IAS 2015 conference in Vancouver, July 19-22. Here, she discusses some of the highlights of her work.

Your research in South Africa found that bringing HIV care closer to people’s communities can have a huge impact. Why?
Health systems are like woven fabrics – when you pull on one thread, the rest of the fabric adjusts. I looked at how a health system responds when you bring HIV care down to the level of the local clinic.

Before this integration, HIV patients had to leave their communities and travel to many facilities, many times. Forty per cent of those who needed HIV treatment weren’t getting it, especially the most economically disadvantaged. Patients don’t have money to pay for transportation and the time to travel far. Many passed away while waiting for treatment.

Patients now have access to comprehensive care at their local PHC clinics. Integration also improved HIV screening and the treatment process for HIV-positive mothers and babies.

In addition, integration highlighted the importance of primary health care. Patients were counselled on potential side effects of their treatment, and learned about their medications. They had treatment buddies and support systems. It puts the patient back into the centre of the health care equation.

There are many advantages for health care workers. Integration improved their skills, confidence and morale. Many nurses said to me, “When I see a patient who was so sick from HIV that he had to be carried into the clinic in a wheelbarrow – and then I see him get better on HIV treatment and return back to work in a few weeks – that makes me feel good. I did that!”

Number of HIV patients on treatment in local clinics in Free State, South Africa (Click image to enlarge)

Number of HIV patients on treatment in local clinics in Free State, South Africa (Click image to enlarge)

What was the impact on the stigma surrounding HIV?
I believe the advantages of integrated care have had an immense impact in terms of decreasing HIV-related stigma. This means HIV patients are treated the same as all other patients – no separate queues, specific consultation rooms or identifiers on files. Patients and health care workers told me that this “normalized” HIV because now it was treated the same way as other conditions, and you weren’t sent far away to a “special” clinic.

Another advantage is that people in a waiting area would strike up conversations about HIV. When HIV patients were seen as productive and healthy members of the community, this shattered images of HIV being a death sentence.

Now that care was nearby, patients could bring a partner or friend to support them. This empowered and unified communities to fight stigma and educate each other.

The massive increase in patients receiving antiretroviral therapy is astounding. How could the clinics handle such a dramatic increase?
You’re right – the increase is phenomenal. And the fact that the provision of primary health care services wasn’t overwhelmed was great.

Many HIV-positive patients were coming to the PHC clinics for all their other health needs. Some health care workers reported that there was not a massive increase in patient numbers – these were patients who lived in the area who should have been coming to the clinics in the first place.

There were also increased efficiencies. Health care workers were no longer spending time on referrals, and protocols and services were streamlined. Our participants felt that integration promoted teamwork. They could treat patients holistically and were able to shift some of their tasks to other care providers, such as community health workers.

The next challenge is really about maintaining high-quality care for all patients within these systems, taking care of the health workers and keeping patients engaged in HIV care across their lifetime – especially as HIV and aging foster new issues.

IAS 2015 is the world’s largest scientific conference on HIV and AIDS. This year’s event is organized by the IAS in partnership with the UBC Division of AIDS and runs from July 19-22.

VIDEO: A preview of Angeli Rawat’s research on HIV treatment expansion in Free State, South Africa.