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 organizations had in the past advised the intensification of the provision of differentiated Array. It is a customer-centric technique that simplifies and adapts HIV to the patient’s personal tastes, while reducing the burden on the physical care system. This in turn reallocates specialized fitness resources to those who desire them.
There are other models for other times in the adventure of a patient’s remedies and in other contexts. In particular, patients with robust antiretroviral treatment deserve to obtain and take their medications effectively, receive help to self-control their adherence and clinical condition, and connect with clinical evaluation 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.
Several inventions have already been implemented. These are some of the demanding situations they faced.
Script extension
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 medicines dispensed
It would be difficult to overestimate the complexity of ensuring a constant source of active drug stocks for thousands of clinics across the country. Trials have demonstrated the acceptability and clinical feasibility of issuing six months of ART, so customers only have to take the drugs twice a year. But there is fear that the distribution of larger quantities of medicines will be burdened with the complexity of administering the pharmaceutical chain of origin.
COVID-19 has driven the increase in the amount of ART provided to 4 months in the Western Cape, where stocks of the applicable regime allow it. It remains to be noted whether this, and even other constructions, can be made sustainable, allowing customers to spend less time collecting drugs.
A delivery service has been established in parts of the Western Cape, where the government reported the successful delivery of more than 240,000 packages of chronic drugs 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 the pharmacy handles more loads similar to delivery requests.
Supporting self-management
To decrease reliance on face-to-face clinical care, patients will need to be trained to manage their own fitness problems. Health promotion and schooling campaigns can contribute to this empowerment, complemented by improved pathways to the clinic if necessary.
Several hotlines have been placed in response to COVID-19 and it will be attractive to see emerging usage data. In Cape Town, Doctors Without Borders has launched a telemedicine initiative. The first data presented at the foreign AIDS convention in mid-July are encouraging. But such projects can paint if complemented through a large number of fitness-trained painters.