Covid-19 promotes innovative hiv service delivery in cape town

South Africa is home to the world’s largest epidemic of HIV, a virus that attacks a person’s immune system, making one more susceptible to other infections. Sustained treatment with

effective antiretroviral therapy (ART) can enable people living with HIV to achieve near-normal life expectancy. But, according to 2019 figures, only two thirds of an estimated 7.7 million

people living with HIV in South Africa were on ART. There is an urgent need to further scale up the ART programme by initiating new patients and welcoming back people returning after

treatment interruptions, while retaining patients already in care. Against this background, 2020 has seen the global spread of a highly infectious novel coronavirus. In response, many

countries imposed severe restrictions on movement, including South Africa. Health services experienced significant disruptions as resources were redirected to community- and facility-based

screening, testing, contact tracing and emergency care for COVID-19 amid heightened infection prevention and control measures. South Africa’s health services were already strained

pre-COVID-19. Its disruptive impact on HIV and other health services was of obvious concern. Health experts highlighted two interacting concerns. Firstly, people with health conditions

including diabetes, hypertension, TB and HIV may be at higher risk of contracting and succumbing to COVID-19. Secondly, clinical management of these conditions may be disrupted. Patients may

worry that a clinic visit increases their risk of contracting COVID-19, while clinics may be overwhelmed by COVID-19-related demands, leaving less capacity to address non-COVID-19 needs.

These two concerns in combination may mean delayed or interrupted treatment would place already higher-risk people at even higher risk of poor health outcomes. Recent evidence has validated

these concerns locally and globally. Crises often present opportunities for innovation. Here we share some thoughts from the Western Cape – the province hit earliest and hardest by the

pandemic – which may be of interest for similar settings elsewhere. Taken together these innovations present opportunities for both patients and providers. They also present challenges that

must be identified, mitigated and overcome if we hope to turn quick fixes into sustainable transformative changes. RECOMMENDATIONS Recommendations for adapting HIV services in the context of

COVID-19 were swiftly produced by the World Health Organisation, the International AIDS Society, independent experts, the South African HIV Clinicians’ Society and the provincial department

of health in the Western Cape. Many of these recommendations were not new. These organisations had previously recommended the scale-up of differentiated service delivery. This is a

client-centred approach that simplifies and adapts HIV services to suit the preferences of patients while reducing the burden on the health system. In turn, this allows reallocation of

specialist health service resources to those who need them. There are various models for different moments during a patient’s treatment journey and in different contexts. Most notably,

patients who are stable on ART need to efficiently receive and take their medication, be supported to self-monitor their adherence and clinical condition and be linked to clinical assessment

and care only when needed. Here’s an example: imagine that until recently you had to queue at the clinic for a whole day every eight weeks to get your HIV medication. But it’s now possible

for you to receive your medication at home, access telephonic support when needed, and only attend the clinic to see a clinician once a year. Various innovations have already been

implemented. Here are some, and the challenges they’ve encountered. EXTENDING SCRIPTS Pre-COVID-19, prescriptions in South Africa were valid for a maximum of six months. Clients with chronic

illnesses were required to visit the clinic for an assessment each time a new script was required, for example at least twice a year. Earlier this year, in response to COVID-19, regulations

were amended to allow prescriptions to be extended for up to 12 months, potentially allowing well-controlled clients to visit the clinic only once a year for their clinical assessment and

new prescription. INCREASING QUANTITIES OF MEDICATION DISPENSED It would be hard to overstate the complexity of ensuring a consistent supply of active medication stocks at thousands of

clinics across the country. Trials have shown the acceptability and clinical feasibility of dispensing six months of ART so that clients only have to collect medication twice a year. But

there have been concerns that dispensing increased quantities of medication adds to the complexity of pharmaceutical supply chain management. COVID-19 has pushed the services to increase

quantities of ART dispensed to four months in the Western Cape where stocks of the relevant regimen allow. It remains to be seen whether this, and even further increases, can be made

sustainable, allowing clients to spend less time collecting medication. PROVIDING MEDICATION FOR COLLECTION OR DELIVERY IN THE COMMUNITY Until recently most HIV patients collected their

medication in person from a clinic. COVID-19 has prompted clinics to attempt various alternative collection and delivery strategies, all of which encountered challenges. Couriering

medication to someone’s home is expensive and requires up-to-date knowledge of the area. In the South African context there are also safety concerns for couriers. A delivery service has been

introduced in some areas in of the Western Cape, where government reported successful delivery of over 240,000 chronic medication packages by mid-June. There have been some challenges, such

as keeping accurate records of successful delivery and promptly following up when they don’t happen. The government has also launched a WhatsApp chat bot called “Pocket Clinic” that enables

patients to update their contact details electronically and request chronic medication delivery. But there are questions about the sustainability of the system as pharmacy staff are

carrying additional burdens related to delivery requests. SUPPORTING SELF-MANAGEMENT In order to decrease the dependency on in-person clinical management, patients must be empowered to

manage their own health conditions. Health promotion and education campaigns can contribute to this empowerment, complemented by strengthened pathways to clinical support when needed.

Various hotlines were set up in response to COVID-19 and it will be interesting to see emerging data on utilisation. In Cape Town, Médecins Sans Frontières launched a telemedicine

initiative. Early insights presented in mid-July at the international AIDS conference are encouraging. But such initiatives can only work if they are complemented by a large number of

trained community health workers. COVID-19 has stretched South Africa’s public health services to capacity. In response, the services have increased their capacity through innovation. Now is

the time to ensure that these innovations form the foundations of sustainable evolution. _We acknowledge and appreciate input from Kirsten Arendse at Médecins Sans Frontières, Erin Roberts

at Western Cape Government and Natacha Berkowitz at City of Cape Town._