Using TIER.Net to Strengthen the HIV Care Cascade

By Tonderayi Macheka May 26, 2016

Strengthening early linkage, treatment adherence and retention in HIV Care using HCT and Pre-ART TIER.Net modules in Limpopo, Mpumalanga and Free State Provinces in South Africa


TIER.Net in South Africa

In 2011, an Electronic Patient Management System (EPMS) called TIER.Net with modules to capture patient-level data on HIV Counselling and Testing (HCT), pre-ART and ART services was introduced in South Africa. This three-tier system was developed by the University of Cape Town (UCT) as a “bridging solution” to the implementation of a fully electronic EPMS (Tier-3). There is increased coverage of public health facilities in South Africa that have transitioned from paper-based recording (Tier-1) to the electronic-based recording (Tier-2) for clients on ART; and the integration of HCT and pre-ART modules is in the early stages of implementation and scale up.  Once fully implemented (HCT, pre-ART and ART modules), allows facilities to track patients across the treatment cascade to effectively monitor the implementation of the 90-90-90 strategy and in turn improve their health outcomes.

To date, the National Department of Health (NDoH) has approved national implementation of the HCT and pre-ART modules, along with the integration of the Electronic Tuberculosis Register (ETR) in TIER.Net.  This will allow complete and comprehensive use of this system beyond its current use as an electronic register. TIER.Net, when fully implemented, also has the potential to become a case based HIV surveillance system for South Africa as its modules generate the required patient level data to measure core WHO indicators. Whilst efforts are in place to increase coverage, scale up has been slow and few facilities have fully implemented these modules, significantly hampering the ability of facilities to follow-up on patients lost to care, and to measure progress towards achievement of the 90-90-90 targets

The LinkCARE project

NASTAD South Africa (NASTAD SA) is currently implementing the LinkCARE program funded by the Centers for Disease Control and Prevention (CDC) through a sub-award from South Africa Partners, and operating in the Free State, Mpumalanga and Limpopo Provinces. The LinkCARE program provides technical assistance for the development and implementation of key aspects of HIV and AIDS care and support services in South Africa and strives to improve patient outcomes by:

  1. Promoting Early Linkage, Treatment Adherence, and Retention in HIV/AIDS Care;
  2. Supporting the nationwide roll-out of the “National Adherence Guidelines for Chronic Diseases (HIV, TB and NCDs)” including Integrated Access to Care and Treatment (I ACT)
  3. Supporting the comprehensive package of care and support services that are part of routine HIV/AIDS care and treatment.
  4. Strengthening the integration and quality of Child and Adolescent friendly services (including transitional services) in the mainstream HIV/AIDS care and treatment.
  5. Supporting the integration of mental health services in routine HIV/AIDS care and treatment services.
  6. Supporting the integration of Quality Improvement and Quality Assurance programmes and interventions in HIV/AIDS care and treatment services.

Technical assistance is provided through (i) reviewing, designing and implementing effective tools for successful programming, (ii) building capacity of human resources, and (iii) improving systems and processes for managing programmes and activities.

Training of health care workers on HCT and pre-ART TIER.Net modules

TIER.Net was identified as a key platform to strengthen linkages, adherence and retention in HIV care, treatment and support. Currently, South Africa has no standard indicators for linkages in the National Indicator Data Set (NIDS). Whilst HCT is provided, there is no formal reporting system to track patients who tested HIV positive, and are linked to care, except when the patient is initiated on ART. Therefore, many pre-ART patients are not accounted for and are lost in HIV care.

As part of LinkCARE, NASTAD-SA, working closely with the Provincial Strategic Information Management Units of the Department of Health, and M&E personnel from the District Support Partners, identified the need to scale up implementation of the HCT and pre-ART TIER.Net modules. To ensure that best practices are used, NASTAD SA met with TIER.Net developers to seek technical guidance and support. Subsequently, NASTAD SA facilitated the training of 385 TIER.Net DOH personnel in all supported Provinces. To date, the roll out of the HCT and pre-ART module is being tracked in selected health facilities as per the Province’s criteria.

Next steps

A quick glance at this activity shows success in terms of buy-in from DOH, collaboration with District Support Partners (DSPs), and enthusiasm to implement and learn lessons. The next step for NASTAD SA is to show how TIER.Net can be used by health facilities, Districts and Provinces to 1) strengthen the care cascade, 2) evaluate progress towards 90-90-90 targets; and 3) enhance evidence-based HIV planning efforts at the district and provincial level.

Dr. Tshiwela Neluheni (NASTAD), Habtamu Girma (NASTAD), and Tony Diesel (South Africa Partners) also contributed to the development of this post.