Challenges in HIV Treatment

                  Although South Africa reluctantly rolled out its government-funded ARV program in 2004, there are still many challenges the government faces in regards to HIV treatment. Two of the key challenges go hand in hand: ARV adherence and program retention. Surprising to some is the fact that South Africa actually has an adherence rate of 90%, one of the highest in the world (Achmat, 2007). This is primarily thanks to the work of NGOs, who often place an emphasis on treatment literacy, community awareness, and primary care clinics. However the same year that Achmat’s paper was published, another study showed that South Africa was suffering in terms of patient retention. The Cornell study found that after one year in treatment there was only a 60-80% patient retention rate, which steadily declined over time (Cornell, 2007). When looking at these papers side by side, one is faced with a surprising juxtaposition: while in treatment patients are very adherent to their medications, yet less patients are adherent to the treatment itself. In the next few years South Africa will have to focus on increasing patient retention rate by exploring the factors that may lead to loss to follow up (LTFU).

Zackie Achmat, HIV activist, with Nelson Mandela

              There are several factors that can lead to increased numbers of LTFU patients. In my opinion the two most important are computational errors and the over-burdening of primary care clinics. Both the Cornell paper and the WHO Global Update on HIV Treatment acknowledge that the estimates of LFTU patients are not completely accurate. It is estimated that anywhere from 33-48% of LFTU patients are actually deceased, and another 12-54% are “self-transfers” who access care at different places (WHO, 2013). Yet this inconsistency is telling, as it reflects the current lack of organization in the government ARV system. A successful program needs to be able to keep track of its patients, whether or not they have died or they are truly LFTU. However while the true number of LTFU patients may be lower than estimated, there are still too many people not retained in the government system. Much of this can be attributed to an over-burdened program that was unprepared for the dramatic increase in patients in recent years. Many clinics just do not have the staff or resources to continuously keep track of their increasing number of patients, and with an estimated 6.3 million HIV-positive South Africans it is not difficult to understand their plight (Class lecture, 6/25/13).

Thabo Mbeki...how many deaths is he responsible for?

                  Luckily there are ways to improve retention rate and decrease the number of LTFU patients. According to the WHO, “several studies…have shown that decentralizing ART services improves retention in care” (WHO, 2013). The studies that they are referring to have found that a district hospital’s retention rate is on average 80%, compared to a regional hospital’s retention rate of 69%. We saw the benefits of decentralized primary care first hand last week during our visit to Gugulethu. At the ARV Club we visited there were less than 30 patients enrolled, which means that it is easier for them to get their medications, and their absence is noted if they do not show up. Another prospect for increasing retention rates is the gradual introduction of FDCs in the public sector. While availability may be currently limited to some prioritized group, taking one pill once a day will certainly lead to more adherences, versus having to take three pills two times a day (Class lecture, 6/25/13).

                  LTFU patients are a big challenge facing the future of ART in South Africa. The main problem isn’t getting people in treatment to adhere to their medications, but it’s getting people to adhere to their treatment after testing HIV-positive. Many factors play into retention rates: statistical errors, poor record keeping, burden of resources on primary care, revival of traditional medicine, social stigma, and AIDS-related deaths. However by focusing on record organization and continuing efforts to decentralize ART care the picture of HIV retention may not look so bleak.

Sources

Achmat, Zackie, and Julian Simcock. "Combining Prevention, Treatment and Care: Lessons from South Africa." AIDS. 21.4 (2007): S11-S20. Web. 2 Jul. 2013.

Cornell, Morna et al. "Temporal Changes in Programme Outcomes Among Adult Patients Initiating Antiretroviral Therapy Across South Africa, 2002-2007." AIDS. 24.14 (2010): 2263-2270. Web. 2 Jul. 2013.

Grimsrud, Anna. Class lecture: Antiretroviral Therapy in South Africa. June 2013.

World Health Organization. Global Update on HIV Treatment 2013: Results, Impacts and Opportunities. Geneva, Switzerland: WHO Press, 2013. Web.

By Leah Rosenbaum