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