Whether or not someone living with HIV in South Africa gets a one- or three-months' supply of antiretrovirals at a time depends partly on the clinic where they happen to go for HIV care. Ahead of World AIDS Day 2024, Elri Voigt unpacks the legal and policy issues relating to prescriptions and HIV medicine refills and asks why people living with HIV are treated so differently in different parts of the country.
As COVID-19 swept through South Africa in 2020, a fascinating natural experiment unfolded in KwaZulu-Natal. In order to reduce crowding at clinics, some people living with HIV were given 12-month prescriptions for their antiretrovirals instead of the usual six-months. Some sharp-eyed researchers soon saw the opportunity to get answers to an important question in HIV care.
Drawing on anonymised health system data, the researchers looked at outcomes of over 27 000 people living with HIV - around 57% of which received 12-month prescriptions. They found that people receiving 12-month scripts were as likely to stay on treatment and as likely to still have the virus under control as people receiving six month scripts. The only real difference between the groups is that those in the six-month group had to make double as many clinic visits as people in the 12-month group.
Though not the final word on the issue, the findings strongly suggest that it is safe to give people who are stable on HIV treatment 12-month scripts and that doing so can help ease the pressure on clinics.
The study provides one of the latest pieces of evidence relating to what is called the differentiated service delivery approach (DSD). As this 2023 paper published in the Journal of the International AIDS Society summarises, DSD programmes want to provide a more person-centred approach for delivering HIV treatment as well as increase the accessibility of treatment among those who are already established on treatment - while allowing "clinical resources to be directed towards acute and unstable patients". In short, the idea is that someone who is newly diagnosed with HIV and struggling should receive much more intensive care than someone who has been on treatment for years and just wants to get on with their life.
Prescriptions and refills
Closely related to the issue of six and 12-month prescriptions is that of multi-month dispensing. A person might for example get a six-month script at the clinic, but then be required to return to the clinic to collect their medicines every month - depending on how many months' supply they are given at a time and whether they are offered the option of collecting medicines from another pick-up point such as a private pharmacy.
Here too the thinking is that allowing people living with HIV to pick up multiple month's supply of their antiretroviral treatment (ART) can drastically reduce the time they spend at healthcare facilities. It could potentially reduce the number of visits to pick up medications from 12 to four visits - or ultimately only two visits - per year. While this is not something that will be appropriate for every person living with HIV, it could significantly reduce the burden for those who don't require close monitoring and management. It could also relieve pressure on healthcare facilities.
Proponents argue that the ideal is to provide access to a six months' supply of treatment to those who are eligible as per recommendations by the World Health Organization (WHO). In its 2021 consolidated guidelines for HIV, the WHO recommends that "people established on ART" should be offered refills of treatment lasting between three to six months - preferably six months if it is feasible to do so.
The WHO defines people established on ART as those who have been on treatment for at least six months and don't have another illness (excluding well-controlled chronic health conditions), who have received good adherence counselling, and shows evidence that their treatment is working.
How multi-month dispensing works in South Africa
Starting in 2014, some people living with HIV in South Africa could get a two month's supply of treatment at a time through the Centralised Chronic Medicines Dispensing and Distribution (CCMDD) system. This system, among others, allows people to collect their medicines at pickup points like private pharmacies rather than always having to go to the clinic. As explained in this research article, through the CCMDD, some people living with HIV only had to go to the clinic every six months to pick up a prescription and then pick up a two-months' supply of treatment at a time from designated pickup points. Accessing this service was open to people living with HIV who were virologically suppressed and had been on treatment for over a year.
Prescriptions can be filled using different dispensing intervals, Dr Anna Grimsrud, Senior Technical Advisor at International AIDS Society, told Spotlight. For example, a six-month prescription can be refilled as six repeats of a one-month supply or three repeats of a two-month supply. The CCMDD system used the latter.
During the COVID-19 pandemic, the CCMDD programme was adapted to allow more clients to receive an uninterrupted supply of ART and to decrease their contact with healthcare facilities. Legislation was temporarily amended to extend these six-month prescriptions to 12 months. The programme was also allowed to give three-month ART refills instead of two-months and expand the eligibility criteria to include people at six-months after ART initiation instead of 12 months. It was these changes that opened the door for the KwaZulu-Natal study discussed at the beginning of this article.
Though some of the temporary measures soon reverted, Dr Andy Gray, a senior lecturer in pharmacology at the University of KwaZulu-Natal, told Spotlight that the COVID-19 pandemic gave added impetus to increasing multi-month dispensing.
The shift was soon reflected in official policy. The 2023 National ART clinical guidelines stated that people living with HIV should be allowed to collect prescriptions for three or even six months' supply of their treatment. The guidelines, Gray explained, refer to the differentiated models of care standard operating procedures. The 2023 revision of standard operating procedures, which apply to HIV, tuberculosis and non-communicable diseases, give specific criteria for two, three, four and six months supplies of medications for these conditions.
Essentially, South Africa's HIV treatment guidelines indicate that most people on ART should get three months of treatment at a time.
Anele Yawa, the general secretary for the Treatment Action Campaign (TAC), told Spotlight the guidelines exclude people who are sick (either struggling to get their viral loads down or sick with other chronic conditions) and need more frequent clinical visits, those starting ART for the first time, children younger than six months and pregnant women from getting a three-months supply. "TAC doesn't agree with the last one, pregnant women also need their HIV care made easier while attending antenatal care," he said.
People starting ART, Grimsrud explained, will be eligible to get a two months' supply of treatment after being on treatment for a month. Then after four months of being on treatment most people living with HIV could start getting a three-months supply if a viral load test shows their treatment is working.
Someone living with HIV cannot receive a three months' supply indefinitely without being monitored at a healthcare facility. In South Africa, Grimsrud said, almost everyone on HIV treatment is seen "clinically" by a healthcare professional every six months. Provided everything is going well, those who are eligible will then continue to receive a six-month prescription, which is dispensed as a three-month treatment supply.
Gray said multi-month dispensing of ART is "a positive development in that it reduces costs for both the health system and patient".
Many people living with HIV also indicate that they would prefer a longer treatment supply, Grimsrud said, and this would "facilitate their adherence and retention".
There are some challenges that can come with multi-month dispensing of ART, but this can be solved with proper supply management and planning as well as good treatment literacy. Grimsrud cautioned that facilities need to make sure there is sufficient supply of HIV treatment to accommodate multi-month dispensing. Patients also need to be educated on the common symptoms and signs of opportunistic infections, so they go back to healthcare facilities if something seems amiss.
It's also important to make sure people living with HIV are able to access their other chronic medications and prevention commodities like contraceptive care, she added, so they don't have to have additional visits to the healthcare facility.
Uneven access
Community-led clinic monitoring group Ritshidze, which TAC forms part of, has been keeping an eye on whether people living with HIV have been able to get a three-months supply of treatment. The organisation collects information from eight of South Africa's nine provinces - it doesn't have a presence in the Northern Cape.
Overall, Ritshidze's data shows that between July and August 2024, 68% of the roughly 13 000 people they surveyed got a three-month supply of treatment at their last visit. Yawa said they expect that between 85% and 90% of people living with HIV should get a three-month supply. This expectation is below 100% because not everyone living with HIV is eligible to get a three-month supply at a time.
Ritshidze found wide variation in the dispensing of a three months' treatment supply across provinces in surveys conducted from July to August. Limpopo performed best, with 79% of the 482 people surveyed saying they received a three-month treatment supply. The worst performing province was the Western Cape, with only 21% of 484 people surveyed saying they got a three-month supply.
Multi-month dispensing of treatment
ProvincePeople surveyed% reporting 3 months supply% reporting 6 month supply
Limpopo48279%1%
Gauteng356178%1%
Mpumalanga118178%4%
North West120676%10%
KwaZulu-Natal366272%9%
Eastern Cape149059%3%
Free State96427%3%
Western Cape48421%9%
*This table shows a breakdown of multi-month dispensing ARV supplies by province between July and August 2024 based on data from Ritshidze. Six month data is less certain due to some initial survey confusion between script length and dispensing period.
2024 Q4 Jul-Sep 2024
Earlier this year, Ritshidze flagged the Free State as the province making the least progress in offering longer ART refills. Two districts stood out: only 11% of 716 people surveyed in Thabo Mofutsanyana and 24% of 554 people in Lejweleputswa reported getting a three-month supply when surveyed in April and June.
Zooming in on individual facilities also shows a mixed picture.
On a positive note, Yawa said a number of facilities are following the guidelines and providing a three-month treatment supply to patients. Between July and August this year, there were 75 facilities where everyone surveyed by Ritshidze said they were given a three-month treatment supply. Gauteng and KwaZulu-Natal each had 23 of these facilities, North West had 21, Eastern Cape had four, Mpumalanga had three, and Limpopo had one.
But Yawa also pointed out that there are facilities that "are progressing extremely slowly" with few or even none of the people surveyed getting a three-month supply of treatment.
It is worth noting that the Ritshidze surveys are by no means universal and do not cover nearly all health facilities in the country. They do however provide arguably the best independent source of data on several important indicators.
Common reasons for falling short
The reasons for the variance between provinces is likely a mix of factors, said Gray. These include individual facility approaches, clinician preferences, budgets and cash flow challenges, and stock availability.
Touching on the last factor, Yawa said stockouts of ART is a pressing issue. "Despite sufficient national stock levels, some provinces, sub-districts, or facilities are not effectively managing supply chain systems, particularly in forecasting, ordering, and timely collection. This may have raised concerns about potential stock shortages," he said. "As a result, there may be specific instructions given to clinicians not to prescribe three-month treatment supply or facilities or individual clinicians independently trying to manage stock levels," Yawa added.
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Another part of the problem, he said, is that some provinces, districts, facilities, or even individual clinicians don't fully understand the long-term benefits of multi-month dispensing. This can result in clinicians being told not to prescribe three-month treatment supplies -- or some facilities or clinicians making that decision on their own, said Yawa.
Adding to this, he pointed out a lack of awareness. Some clinicians may not realise they're supposed to provide scripts for three-month supplies or don't know how to adjust their prescribing when stock is low. On top of that, many people living with HIV don't demand their right to a three-month supply because they don't know they're entitled to it.
Improving access to six-month refills
TAC is calling for greater access to six-month treatment refills. "The reality is that there is very limited six-month treatment supply being given out - and where it is, it is for those who really need it, like people who are highly mobile," Yawa said. "Where six-month treatment supply is being given, this should continue while planning and forecasting takes place for a broader six-month treatment supply roll out."
Yawa urged that such plans should be finalised quickly. "We need National and Provincial Departments of Health to urgently finalise their planning and forecasting processes to confirm operational capacity and prepare for six-month treatment supply roll out by the end of the year," he said. This "simple intervention", said Yawa, can lead to easing the financial burden of people living with HIV while also improving their health outcomes.
"More people collecting their treatment and therefore taking their treatment correctly, means less severe illness, [and thus] decongesting our overburdened public sector hospitals. Less unnecessary visits to clinics also means decongesting primary care facilities, meaning better primary care for all," he said.
Grimsrud also weighed in on this issue, stating that data from neighbouring countries that have implemented and scaled up six-month treatment refills indicate that this approach is feasible for South Africa.
Spotlight sent questions to the National Department of Health for this story. The department acknowledged receipt of our questions, but despite several follow-ups had not provided responses by the time of publication.
Disclosure: The TAC is mentioned in this article. Spotlight was previously published by SECTION27 and the TAC, but since late 2023 Spotlight is published by just SECTION27. Spotlight is editorially independent - an independence that the editors guard jealously. Spotlight is a member of the South African Press Council.
