Enhancing Antiretroviral Therapy Initiation for Hospitalized and Recently Discharged People Living With HIV in Johannesburg, South Africa

Natasha Davies; Melanie Bisnauth; Kate Rees

doi:10.9745/GHSP-D-24-00017

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FIGURE 1
In-hospital Case Finding and Antiretroviral Therapy Initiation, Johannesburg, South Africa
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FIGURE 2
Post-Discharge 28-Day Follow-Up Component, Johannesburg, South Africa
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FIGURE 3
Time to ART Initiation in Implementing Hospitals, Johannesburg, South Africa, May 2020 to March 2021
Data source: Intervention data.
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FIGURE 4
ART Linkage Rate Pre-implementation, Early Implementation, and Full Implementation, Johannesburg, South Africa
Data source: DHIS.

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TABLE 1.

Comparison of Standard Practice for PHC-Based HIV Services, Pre-Intervention, and Post-Intervention Hospital HIV Services, Johannesburg, South Africa

	PHC Facilities	Before Intervention: Hospitals	After Intervention: Hospitals
HTS	Lay counselors provide HTS Nurse clinicians offer PICT to all HIV negative/unknown status PHC clients Point-of-care rapid antibody tests with immediate results communicated to client HIV tests and results recorded in national HIV testing register	Doctor-driven PICT inconsistent, particularly in nonmedical wards, may order lab-based ELISA Lay counselors conduct rapid HIV testing only on doctor referral Results often unavailable before discharge ELISA results not captured in register	Lay counselor-driven Daily counselor ward rounds for new admissions Bedside rapid point-of-care antibody HIV tests Immediate communication of results to patient and NIMART nurse HIV test and result recorded in national HIV testing register
ART initiation	Lay counselors refer all clients to facility NIMART for same day initiation if eligible Standard clinical stationery used and captured daily onto database (i.e., TIER.Net)	ART initiation dependent on available ELISA result pre-discharge & sufficiently trained/confident doctor No NIMART nurses in hospitals Often deferred for initiation at PHC facility Initiation data often not captured on TIER.Net	Provincial permission for NIMART nurses’ appointment Counselors refer clients for bedside same day ART assessment/ initiation NIMART nurses work with ward doctors Standard clinical stationery used and initiations captured weekly on TIER.Net
Linkage to ART continuation or deferred ART initiation	TIER identifies missed appointment or loss to follow up after initiation Lay counselors provide adherence/treatment literacy sessions Monitoring: follow-up visits on standardized clinical stationery, captured on TIER.Net, enables tracing/recall of missed appointments NAG standardized approach	Inconsistent use of stationery Limited mechanisms to confirm linkage ART continuation post-discharge Poor hospital-PHC facility referral pathways Inconsistent NAG implementation with limited adherence/treatment literacy counseling	New clients referred to linkage officer for NAG -based adherence/treatment literacy counseling Standardized transfer letter from NIMART nurse accompanies discharge summary Linkage officer discusses discharge plan and provides 28-day telephonic follow-up Linkage officer completes 28-day register Data capturer captures transfers on TIER.Net

Abbreviations: ART, antiretroviral therapy; ELISA, enzyme-linked immunosorbent assay; HTS, HIV testing and counseling services; NAG, National Adherence Guidelines, NIMART, nurse initiated and managed ART; PHC, primary health care; PICT, provider-initiated counseling and testing; PLHIV, people living with HIV.

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TABLE 2.

Benefits, Challenges, and Learnings for Hospital HIV Services Model, Johannesburg, South Africa

Step	Benefits	Challenge/Learning
Department of Health approved transfer letter	Facilitated hospital to PHC transition Communicates medical management to receiving team improving continuity	Few challenges but printed transfer letters must be available Client must be informed that they need to present letter at PHC
Hospital and PHC-based linkage officer liaison	Enabled tracking of mobile individuals after discharge Enabled early identification and intervention for those whose arrival was delayed	Availability of mobile phone data and network High staff turnover at PHCs An electronic referral system could mitigate these
Team interactions with data capturers	Weekly review of 3 registers (HIV testing, NIMART, linkage officer tracking) and use of TIER.Net ensured accurate capturing Accurate data capturing supported quality reporting and evaluation, with rapid identification of gaps	Network connectivity and database downtime leading to back capturing Feedback from PHC linkage officers was often delayed Paper-based and non-integrated systems
Comprehensive 28-day client support	28 days of personalized telephonic follow up by a known linkage officer was the cornerstone of this model Consistent, supportive, individualized follow-up contributed 15% to overall linkage	Incorrect numbers, no answer, network issues often meant individuals could not be reached, even on several attempts In future, with consent, a next of kin or treatment supporter number would be useful AI/chatbot models may be considered for alternative support