Health systems barriers to adherence in
antiretroviral treatment programmes in rural
South Africa
Dr Brian van Wyk
School of Public Health
University of the Western Cape
Dr Fiona Larkan
Centre for Global Health
Trinity College Dublin
BACKGROUND
•
South Africa has the largest number of people with HIV:
5.38 million (mid-year estimate Statssa 2011)
•
Largest public ART programme worldwide: 1.4 million
•
National HIV counselling and testing campaign aim to test
15 million people by 2011
•
This will further increase the number of people needing
HIV treatment, care and support.
CHALLENGES
• Human resources for health shortages
• Late initiation of treatment
• Sustaining large numbers of people on treatment
and in care
• Adherence to treatment in ART programmes
POOR
ADHERENCE
Patient
factors
• Psychosocial
• Knowledge of
treatment
• Social support
• Disclosure
• Attitudes &
Beliefs
• Substance Use
• Travel
• Work
Health
services
factors
Treatment
factors
•
•
•
•
Pill burden
Side effects
Formulation of
Drugs
Opportunistic
Infections
•
•
•
•
Patient
Provider
relationship
Availability of
Drugs
Quality of
Care
Waiting
Times
Sociopolitical
factors
•
•
•
•
Stigma
Discrimination
Unemployment
Structural
violence
METHODOLOGY
•
3 year ethnographic study in 3 sites in peri-urban and rural
Western Cape funded by a Global Health Research Award
(GHRA 2007/8)
•
Aim: to explore barriers to access and adherence to HIV
treatment
•
Methods: qualitative interviews, participant observations
•
Sample: patients on pre-ART and ART, identified at health
facilities and in the community
•
Key informants: nurses, doctors, pharmacists, home-based
carers and community health workers
MAIN FINDINGS:
PATTERNS OF ADHERENCE
1. Unplanned treatment holiday
6 months on/off; 9 months on/ 3 months off
2. Non-compliant
Chaotic adherence
3. Partying
6 days on/ one day off
4. Playing
10 weeks on/ 2 weeks off
5. Secretive
skips two or three doses of medication per week
TYPE OF PATIENT
INTERVENTION
REQUIRED
POLICY
POLICY/
IMPLEMENTATION
GAP
(Unplanned)
Treatment holiday
• Plan for treatment
holidays;
• Entry to HIV
treatment only via
testing
• No support
• No sharing of records
between facilities
• Need for social
capital, work
opportunities
• Counselling in preART
• Social disability
grant
• Integrated case
management that
includes welfare of
patient
• Training for lay
counsellors on
substance use and
nutrition
• “Positive living”
Chaotic
• Treatment literacy
• Food/living support
Partying
• Education about
alcohol use
• Mixed messages
about alcohol and
medication in TB
and HIV
programmes
Playing
• Education about CD4
count and health
status
• Temporary disability • Disability grant = de
grant for 6 months
facto poverty
alleviation grant
Secretive
• Support to disclose
status
• Identify treatment
buddy in pre-ART
• Stigma and
discrimination in
community.
“Sick clinics”
•
System fails the patient by not providing the necessary support for
health service delivery
•
Moreover, in one case we found the clinic itself to be dysfunctional
and hence the primary cause of non-adherence for its patients
•
Designated district level ART clinic for a large catchment area
•
Funding ring-fenced for ART clinic which was based on the
grounds of regional hospital
•
Competition for financial resources (and consequent lack of cooperation) between two ‘separate’ facilities
•
Inability to retain doctors to work in rural environment (5 doctors
in 6 months)
•
Disruption of service to patients – patients sent away and told to
‘come back another day’.
Acknowledgements
•
Team members: Fiona Larkan, A Jamie Saris, Thato Ramela and
Paschaline Stevens
•
Supported by CDPC
•
Funded by GHRA 2007/8 (Irish Aid and HRB)