The percentage of people living with HIV receiving a three to six-month supply of ARVs at a time in the Free State has dropped from 13% last year to 3% this year, making the province the worst performer in multi-month dispensing of ARVs in the country. This while in Mpumalanga, 64% of people living with HIV receive a three to six-month refill as per national guidelines.
This is according to the latest figures from community-led clinic monitoring group, Ritshidze. In its third Free State report, released on 30 August, the group notes several challenges faced by people living with HIV, key populations that include men who have sex with men and sex workers, among others, and other public healthcare users in the province. Among these are a lack of multi-month dispensing of ARVs and long waiting times at clinics, two factors that can make it harder to take treatment as prescribed.
The report notes that multi-month dispensing often allows people living with HIV to collect their treatment at pick-up points situated at healthcare facilities or externally in the community, making it quicker and easier to collect ARVs. Yet the monitoring data shows that 41% of people using facility pick-up points said they still have to collect files, take vitals, and see a clinician before getting their parcel, which adds to unnecessary delays. "Overall, these shortcomings contribute to slow progress towards getting everyone to start and stay on HIV treatment," the report states.
Monitoring for the new report was done in April and May this year at 21 facilities and included interviews with 1 095 public healthcare users across four districts in the province. Of the public healthcare users interviewed, 47% (516) were people living with HIV (PLHIV) and 16% (180) were younger than 25.
The recommendations
The report stresses that multi-month dispensing of antiretroviral treatment is just one of several ways to help reduce the burden on the healthcare system, and to reduce the pressure manifesting in long waiting times, overcrowded clinics, and overworked clinic staff. Ritshidze recommends - as it did in its two previous Free State reports - that "the department extends and implements refills up to three months by end of December 2023, and six months by end of September 2024". It is also recommended that the department, "Ensures that all people living with HIV are offered a range of repeat prescription collection strategy options", "that facility pick-up points are one-stop very quick ART collection-only, that clinic visits are under 30 minutes and there is no need to go to the clinic registry, collect folders, and to see a clinician.
"Multi-month dispensing and repeat prescription collection strategies can simplify and adapt HIV services across the cascade in ways that both serve the needs of people living with HIV better and reduce unnecessary burdens on the health system," the report notes.
As people living with HIV often report that healthcare workers send them to the back of the queue when they miss appointments, Ritshidze recommends that staff acknowledge and understand the importance of ART continuity, that it is normal to miss appointments, and that no person living with HIV should be sent to the back of the queue if they miss an appointment as per the welcome back campaign strategy. Ritshidze also recommends that clinics must not require transfer letters to restart or continue with ART and any reports where treatment is delayed by healthcare workers requiring a transfer letter should be urgently investigated and disciplinary action taken where appropriate.
The value of multi-month dispensing
The value of multi-month dispensing is well established. Study findings on the HIV programme in Ethiopia released in May this year, for example, stressed that multi-month dispensing of antiretroviral therapy is "an integral component of differentiated HIV service delivery for people living with HIV". Ethiopia was the first African country to implement six-month dispensing at scale.
The benefits cited by study participants included "time and cost-savings, fewer work disruptions, reduced stigma due to fewer clinic visits, better medication adherence, and improved overall health". The perceived health system-level benefits included "improved quality of care, decongested facilities, reduced provider workloads, and improved record-keeping".
According to Clinical Director at the Southern African HIV Clinicians Society, Camilla Wattrus, requiring people to visit healthcare facilities monthly to collect routine medication, can place a huge strain on the available resources in these facilities.
"Multi-month dispensing for eligible, stable patients on chronic medications, including ARVs can help to alleviate some of this burden, easing up the staff's available time towards those with acute conditions and unstable patients, says Wattrus.
She says multi-month dispensing is also one way to increase access for stable patients to their medication by reducing potential adherence barriers leading to poor health and loss of income due to transport costs and time away from work - all factors identified by Ritshidze through its monitoring. External pick-up points can also help alleviate congestion at facilities and reduce waiting times.
When asked what the Free State health department can do to improve its performance on multi-month dispensing, Wattrus says establishing clear eligibility criteria will work because not all patients may be suitable. She says that patient education is vital so that they understand the importance of adherence.
"Knowing how to take and store medication, knowing where and when to collect medication, when to return for appointments, and understanding that they can return to the facility at any time they feel unwell or in the case of an emergency is very important. Adequate supply chain management to ensure an uninterrupted supply of medication along with accurate record-keeping and communication is vital," she says. "Pharmacists, prescribers, and other staff members involved must also be adequately trained on how to deliver multi-month dispensing."
Wattrus says in order for the Free State to do well, there needs to be an improved supply chain management system, adequate training for all involved staff, and a well-functioning pick-up point system implemented.
The reality on the ground
However, founder of the lesbian, gay, bisexual, and transgender (LGBT) organisation, Free State Rainbow Seeds, Thabiso Chaka says the Free State can do better in expanding external pickup points. "Once a person has shown interest and is also adhering to their medication, it is a bonus to say now you don't have to come to the facility every month and every day. You can come after every three to six months. "I believe it is a good strategy to ensure that people adhere to their treatment. The reason why the Free State is doing poorly is because there is also not enough treatment viral load literacy and this creates a serious challenge and the level of care is often compromised because facilities are congested," says Chaka.
"As the Free State Rainbow seed, we also want to become a CCMD point where we can be able to issue three to six months because by so doing our people will be comfortable." CCMD (Central Chronic Medicines Dispensing and Distribution) is a government programme that enables stable patients to collect chronic medicines dispensed centrally from designated pick-up points. Chaka says multi-month dispensing of ARVs "is a good approach to limit issues of defaulting because the stigma attached to HIV-positive people is still there".
According to Judy Mokoena from the Treatment Action Campaign (TAC) in the Free State, there are many reasons why the provincial department is struggling with multi-month dispensing of ARVs.
"The first one is that most facility managers and pharmacists order medication too late. Another reason is that they do not have an actual database of people living with HIV who come to their facilities. What I have noticed is that most people in the province still receive their medication inside the facilities. As TAC, we have been emphasising the issue of giving patients a supply of three to six months, but they are failing dismally," she says. "Every year we ask the same questions when it comes to the multi-month dispensing, but there has not been a clear answer from government."
"ARV shortage and ARV theft also play a role and could be another reason why the government is struggling to provide three to six months' supply," says Mokoena. "In the past, we have had challenges of stockouts in the Free State."
Free State government responds
Spotlight approached the district health managers in Lejweleputswa district and Thabo Mofutsanyana district for comment but they referred all queries to the health communications team, who then issued a statement on Ritshidze's findings.
The provincial health department calls Ritshidze's report "a constructive model of engagement between the department and the advocacy groups". "As the Free State Department of Health, we acknowledge the report which identifies areas of weakness in service delivery and also provides an opportunity for corrective measures to be taken and improvements to be effected," the statement reads.
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The statement states that the Free State Department of Health has subsequently outlined remedial actions. "The remedial action to be effected by the department is that significant improvement was made for patients receiving two months' supply from 61% in 2022 to 87% in 2023. A provincial resolution was made for a phased-in approach for the implementation of the three-month refill, starting with patients receiving ARTs and other multi-morbidities. This resolution will be re-visited by the end of the third quarter in December 2023."
"On PrEP, the recommendation was that there is a need to ensure that HIV prevention tools, including lubricants, external and internal condoms, Pre-exposure prophylaxis (PrEP), and Post-exposure Prophylaxis (PEP) are made easily available at all public health facilities," the statement reads. A total of 6 923 clients in the province have received PrEP to date, according to the department. (You can read the full statement here.)
In an interview with Spotlight in December last year, Free State health spokesperson, Mondli Mvambi said the department continues to give healthcare users a two-week supply of medication at some clinics because some of the patients "go to clinics and steal medication". "We have identified people who are clinic hoppers who steal medication. When they get three months' supply, they go to another clinic to get another three months' supply. So to curb this practice, we keep people on 14 days' supply. The idea is to give them a few days because they claim to have forgotten their clinic cards," he said at the time.
Meanwhile, the numbers for retaining people living with HIV on treatment are not looking great in the province. In the department's last tabled annual report, the department stated that it failed to meet its target for retaining adults on ART in care. The ART adult remain-in-care rate in 2019/20 was 68%. In 2020/21, it dropped to 52.8%, and in 2021/2022 it climbed to 67.3%. Among the reasons the department gives for these numbers are the high number of loss to follow-up of clients and "poor tracing by community healthcare workers due to poor supervision".
NOTE: A member of the TAC is quoted in this article. Spotlight is published by SECTION27 and the TAC, but is editorially independent, independence that the editors guard jealously. Spotlight is a member of the South African Press Council.
