South Africa is home to the world's largest epidemic of HIV, a virus that attacks a person's immune system, making one more susceptible to other infections. Sustained treatment with effective antiretroviral therapy (ART) can enable people living with HIV to achieve near-normal life expectancy. But, according to 2019 figures, only two thirds of an estimated 7.7 million people living with HIV in South Africa were on ART.
There is an urgent need to further scale up the ART programme by initiating new patients and welcoming back people returning after treatment interruptions, while retaining patients already in care.
Against this background, 2020 has seen the global spread of a highly infectious novel coronavirus. In response, many countries imposed severe restrictions on movement, including South Africa. Health services experienced significant disruptions as resources were redirected to community- and facility-based screening, testing, contact tracing and emergency care for COVID-19 amid heightened infection prevention and control measures.
Firstly, people with health conditions including diabetes, hypertension, TB and HIV may be at higher risk of contracting and succumbing to COVID-19. Secondly, clinical management of these conditions may be disrupted. Patients may worry that a clinic visit increases their risk of contracting COVID-19, while clinics may be overwhelmed by COVID-19-related demands, leaving less capacity to address non-COVID-19 needs.
These two concerns in combination may mean delayed or interrupted treatment would place already higher-risk people at even higher risk of poor health outcomes.
Crises often present opportunities for innovation. Here we share some thoughts from the Western Cape - the province hit earliest and hardest by the pandemic - which may be of interest for similar settings elsewhere. Taken together these innovations present opportunities for both patients and providers. They also present challenges that must be identified, mitigated and overcome if we hope to turn quick fixes into sustainable transformative changes.
Recommendations for adapting HIV services in the context of COVID-19 were swiftly produced by the World Health Organisation, the International AIDS Society, independent experts, the South African HIV Clinicians' Society and the provincial department of health in the Western Cape.
Many of these recommendations were not new. These organisations had previously recommended the scale-up of differentiated service delivery. This is a client-centred approach that simplifies and adapts HIV services to suit the preferences of patients while reducing the burden on the health system. In turn, this allows reallocation of specialist health service resources to those who need them.
There are various models for different moments during a patient's treatment journey and in different contexts. Most notably, patients who are stable on ART need to efficiently receive and take their medication, be supported to self-monitor their adherence and clinical condition and be linked to clinical assessment and care only when needed.
Here's an example: imagine that until recently you had to queue at the clinic for a whole day every eight weeks to get your HIV medication. But it's now possible for you to receive your medication at home, access telephonic support when needed, and only attend the clinic to see a clinician once a year.
Various innovations have already been implemented. Here are some, and the challenges they've encountered.
Pre-COVID-19, prescriptions in South Africa were valid for a maximum of six months. Clients with chronic illnesses were required to visit the clinic for an assessment each time a new script was required, for example at least twice a year. Earlier this year, in response to COVID-19, regulations were amended to allow prescriptions to be extended for up to 12 months, potentially allowing well-controlled clients to visit the clinic only once a year for their clinical assessment and new prescription.
Increasing quantities of medication dispensed
It would be hard to overstate the complexity of ensuring a consistent supply of active medication stocks at thousands of clinics across the country. Trials have shown the acceptability and clinical feasibility of dispensing six months of ART so that clients only have to collect medication twice a year. But there have been concerns that dispensing increased quantities of medication adds to the complexity of pharmaceutical supply chain management.
COVID-19 has pushed the services to increase quantities of ART dispensed to four months in the Western Cape where stocks of the relevant regimen allow. It remains to be seen whether this, and even further increases, can be made sustainable, allowing clients to spend less time collecting medication.
Providing medication for collection or delivery in the community
Until recently most HIV patients collected their medication in person from a clinic. COVID-19 has prompted clinics to attempt various alternative collection and delivery strategies, all of which encountered challenges. Couriering medication to someone's home is expensive and requires up-to-date knowledge of the area. In the South African context there are also safety concerns for couriers.
A delivery service has been introduced in some areas in of the Western Cape, where government reported successful delivery of over 240,000 chronic medication packages by mid-June.
There have been some challenges, such as keeping accurate records of successful delivery and promptly following up when they don't happen.
The government has also launched a WhatsApp chat bot called "Pocket Clinic" that enables patients to update their contact details electronically and request chronic medication delivery.
But there are questions about the sustainability of the system as pharmacy staff are carrying additional burdens related to delivery requests.
In order to decrease the dependency on in-person clinical management, patients must be empowered to manage their own health conditions. Health promotion and education campaigns can contribute to this empowerment, complemented by strengthened pathways to clinical support when needed.
Various hotlines were set up in response to COVID-19 and it will be interesting to see emerging data on utilisation. In Cape Town, Médecins Sans Frontières launched a telemedicine initiative. Early insights presented in mid-July at the international AIDS conference are encouraging. But such initiatives can only work if they are complemented by a large number of trained community health workers.
COVID-19 has stretched South Africa's public health services to capacity. In response, the services have increased their capacity through innovation. Now is the time to ensure that these innovations form the foundations of sustainable evolution.
We acknowledge and appreciate input from Kirsten Arendse at Médecins Sans Frontières, Erin Roberts at Western Cape Government and Natacha Berkowitz at City of Cape Town.
Jonathan Euvrard, Epidemiologist, University of Cape Town and Mary-Ann Davies, Associate Professor and Director of the Centre for Infectious Diseases Epidemiology and Research, University of Cape Town