Supporting People Living with HIV, TB, and Non-Communicable Diseases in South Africa

By Tshiwela Neluheni December 5, 2016

Co-authors: Nokuthula Futwa, Tonderayi Macheka, Anthony Diesel and Sithembiso Msomi

The Joint United Nations Programme on HIV/AIDS (UNAIDS) 2015 report estimates that 6,700,000 adults in South Africa between the ages 15-49 are living with HIV. Three and a half million South Africans living with HIV were on antiretroviral treatment (ART) by the end of May 2016—the highest number of people on ART in the world.

In an effort to improve ART coverage, and achieve the UNAIDS 90-90-90 targets, the country adopted the Universal Test and Treat (UTT), or “Test and Treat for All”, policy for everyone who tests HIV positive. Offering HIV treatment immediately after diagnosis, regardless of CD4 cell count, this policy will increase the number of people living with HIV (PLHIV) on ART. ART improves health outcomes and prolongs life. It is, however, a lifelong treatment, and living longer increases the likelihood that people on ART may also suffer from other chronic diseases that require lifetime medications, such as hypertension (HPT) or diabetes mellitus (DM).

South Africa has experienced an unprecedented increase in the number of people living with non-communicable chronic diseases (NCDs), such as HPT or DM. NCDs are now among the top 10 leading causes of death in the country. Additionally, the tuberculosis (TB)/HIV co-infection rate is above 60% in South Africa, and TB is one of the major causes of HIV-related mortality. 

With so many individuals on multiple lifetime medications, retention and adherence to treatment becomes a challenge. In response to these challenges, the National Department of Health (NDOH) developed the comprehensive National Adherence Guidelines (AGLs) for HIV, TB and Non-Communicable Diseases (NCDs). These guidelines aim to strengthen early linkage to care, retention, and adherence to treatment for patients on chronic medication. Under the South Africa Partners (SAP) led CDC-funded LinkCARE program, NASTAD is sub-awarded to provide technical support to the National and Provincial Departments of Health in the three NASTAD-supported provinces—Free State, Mpumalanga, and Limpopo—for the development and implementation of key aspects of HIV/AIDS Care and Support services in South Africa, including effective translation of the AGLs into good practice. 

National Adherence Guidelines Dissemination Process 

Diagram 1 below depicts the process followed in the development and dissemination of the AGLs, from guideline development at the national level to preparing provincial and district officials to plan, implement, and monitor AGLs implementation at the facility level.  

Diagram 1: AGLs Dissemination Process

AGLs Dissemination Process

(Click to enlarge)

Training South African Health Department Staff

Training health department staff on how to implement these new guidelines is critical to their success. As part of the LinkCARE program, NASTAD-SA supported the Regional Training Centres (RTC)—who play an overall coordination role for training in the Provinces—in conducting a series of workshops. Together, we provided Provincial Department of Health (PDOH) and District Department of Health (DDOH) officials with an overview of the AGLs during a one-day workshop. PDOH and DDOH programme managers responsible for overseeing the implementation of the guidelines went through a three-day training to provide them with detailed information of the AGLs and guide their planning, implementation, and monitoring of the AGLs execution.

With technical assistance and support from the Provincial Technical Advisor (PTAs), and other LinkCARE technical staff, NASTAD-SA continues to support PDOHs to convene Provincial Technical Working Group (PTWG) meetings and strengthen the HIV Care and Support PTWGs tasked with leading and monitoring the implementation of the AGL through regular technical review.

Lessons Learned

There is still much to do, but we have learned a lot so far:

  • The process of disseminating, implementing, and monitoring the AGLs should be owned and led by the Department of Health to ensure ownership and long-term sustainability of the programme beyond LinkCARE funding timelines. 
  • Inclusion of programme managers during the training, specifically for NCDs, proved to be beneficial as managers could expand on the diseases and provide some background on the necessity to include these conditions in the AGLs.
  • As the Provincial Technical Support Partner, it is important that NASTAD-SA and other LinkCARE partners works closely with the district support partners (DSPs), who have the mandate to support AGLs training, mentoring, implementation, and monitoring at district and facility level.
  • Orientation of all staff at the AGLs implementing sites (including the facility manager, professional nurses, data capturers, and social workers) is key to ensuring that all staff roles and responsibilities are clear to assure a successful AGLs implementation.

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