Transition from Community- to Facility-based I ACT Implementation in South Africa

By Tshiwela Neluheni March 17, 2015

Linkage to and retention in HIV care amongst people living with HIV (PLHIV) have been identified as serious challenges in South Africa, where the HIV prevalence rate among adults aged 15-49 is estimated to be 19.1%. In the age of Treatment as Prevention, and in a country with an estimated 6.3 million PLHIV – the greatest number of PLHIV in any country in the world – linkage to and retention in HIV care is particularly critical. In an effort to help improve these outcomes, NASTAD South Africa collaborated with Mpumalanga Provincial Department of Health (PDOH) and the Regional Training Centre (RTC) to implement the Integrated Access to Treatment and Care (I ACT) program.

The I ACT program focuses on helping PLHIV link to and be retained in care, as well as maintain adherence to antiretroviral therapy (ART). The program targets people recently diagnosed with HIV and recruits them into community and health facility based pre-ART and ART care and support group sessions. These support group sessions provide critical information about HIV, healthy living strategies, and treatment and care options, and help improve retention in care from the time of HIV diagnosis through ART initiation to lifelong care and treatment.

Mpumalanga is one of nine provinces in South Africa, with a population of 4,229,300, 7.8% of the total population in South Africa. The estimated HIV prevalence in Mpumalanga is 14.1%.

During the first three years of I ACT implementation (2011-2013), a community-based model was implemented whereby 237 Support Group Facilitators (SGFs) from community-based organisations (CBOs) were recruited and trained to facilitate I ACT support groups within the community. By September 2013, only 47 (20%) of the 237 SGFs were found to be active and implementing I ACT, with only 32 health facilities engaged. The high rate of SGFs attrition was attributed to the interruption of CBO funding from the PDOH, and the community-based model was thus found to be an unsustainable approach.

Using lessons learned and best practices from implementing I ACT in the Free State, NASTAD South Africa partnered with the Mpumalanga PDOH HIV/AIDS, STI & TB (HAST) Directorate to design a stronger and more sustainable implementation model. The NASTAD/ Mpumalanga DOH collaboration explored strategies to support and expedite the scale-up of I ACT implementation in Mpumalanga through 1) strengthening the provincial I ACT implementation ownership structures and, 2) reengagement of the trained SGFs lost to the system or the training of new SGFs.

In January 2014, the PDOH assigned a provincial I ACT point person to lead and champion provincial I ACT implementation, and in consultation with NASTAD South Africa, decided to transition I ACT implementation from a community-based to a facility-based model. To execute this new model, NASTAD, the PDOH, and the RTC acknowledged HIV Counselling and Testing (HCT) as the key facility-level entry point for identifying PLHIV who should be linked and enrolled into care. Consequently, facility-based HCT counsellors and health promoters were trained as SGFs so that I ACT support group facilitation could be integrated into their standard daily duties. A total of 91 HCT counsellors and health promoters from 91 facilities in all three districts in Mpumalanga were trained to implement facility-based I ACT.

To strengthen implementation of facility-based I ACT and promote buy-in and ownership, district, sub-district and facility based PDOH personnel in all three districts received I ACT sensitization training. A district level I ACT focal person was designated to coordinate, integrate, support and manage the implementation of I ACT in all three districts. With this strong provincial I ACT leadership and guidance, the districts fully embraced the I ACT strategy and saw it as an important tool to enhance the PDOH Wellness Program for PLHIV and to strengthen linkage to care, retention in care and adherence to ART.

The transition from community to facility-based I ACT implementation resulted in a considerable increase in the number of PLHIV enrolled into I ACT support groups in Mpumalanga. Between October 1, 2013 and September 30, 2014, 9,237 PLHIV had participated in I ACT, a 45% increase compared to the same period in 2013 (4,120), and I ACT is now being routinely implemented in 151 health care facilities in Mpumalanga.

Going forward, NASTAD South Africa will monitor and evaluate the effect of facility-based I ACT implementation on the rates of linkage to care, retention in care and adherence to ART.  The results will be used to strengthen the investment case for the adoption and inclusion of the I ACT strategy in the National Adherence Strategy that is still in draft form and awaiting National Executives’ approval.

If you are interested in learning more about what NASTAD is doing in South Africa to improve access and adherence to pre-ART care and ART treatment, please contact Habtamu Girma.

Visit to learn more about the NASTAD Global Program, and to learn more about the I ACT program in South Africa.