Public-sector ART in the Free State Province, South Africa: Community support as an important determinant of outcome
Introduction
As has been observed in many industrialized countries, the provision of antiretroviral (ARV) treatment (ART) can transform AIDS from a deadly disease into a more manageable, albeit still incurable, chronic illness (Bucciardini et al., 2006, Gifford and Groessl, 2002, Mocroft et al., 1998, Wouters et al., 2007). The treatment outcomes for large-scale public ART programs in developing countries, although promising, are still preliminary (Baggaley, 2006, Fairall et al., 2008, Larson et al., 2008). As Ferradini et al. (2007) stated, medium- to long-term studies of patient cohorts are still scarce and have usually involved very limited numbers of patients (DART Virology Group and Trial Team, 2006, Diabaté et al., 2007, Ferradini et al., 2007, Wouters et al., 2009).
There are many challenges in successfully scaling-up ART in resource-limited settings. Although we acknowledge the still significant gaps in financing, shortages of human resources for healthcare are often cited as the most important obstacle to successful treatment scale-up (El-Sadr and Abrams, 2007, Schneider et al., 2006, Van Damme et al., 2008). Ample pilot studies have demonstrated good performances in terms of adherence, treatment success, and survival (Coetzee et al., 2004, DART Virology Group and Trial Team, 2006, Diabaté et al., 2007, Orrell et al., 2003). However, this success rests on a significant human resource base because, although ART is highly effective, its management is complex. The large numbers of patients eligible for treatment, combined with the labor-intensive nature of public-sector ART programs, overstretch the public-health system and overburden healthcare staff. This is the case in South Africa (Gilbert, 2006, Van Damme et al., 2006) and specifically in the Free State Province (Schneider, Hlophe, & Van Rensburg, 2008).
Where health systems require strengthening, the mobilization of the full human resource is necessary to ensure a successful comprehensive AIDS strategy (Pronyk et al., 2008, Schneider et al., 2006, Van Damme et al., 2008). In a recent Special Issue of Social Science & Medicine on Future Health Systems, Standing et al. (2008) and Van Damme et al. (2008) proposed that community mobilization is a possible strategy with which to meet treatment needs in the countries of southern Africa (Standing et al., 2008, Van Damme et al., 2008). In practice, the Médecins Sans Frontières program in Lusikisiki, Eastern Cape Province, South Africa, has shown that engaging the community in HIV/AIDS care can improve the quality of care (MSF (Médecins Sans Frontières), 2006), providing social support and counseling when health professional roles must be limited to technical medical tasks because of human resource shortages (Standing et al., 2008). South Africa's Operational Plan for Comprehensive HIV and AIDS Care, Management and Treatment values these community support initiatives ‘as an indispensable extension of the reach and strength of professional involvement in ART services’ (Department of Health, 2003). However, their potential capacity to address the overwhelming human resource challenges in HIV care is inadequately understood (Pronyk et al., 2008, Schneider et al., 2008), making a systematic assessment of these programs and activities an urgently required research topic (Lehmann & Sanders, 2007).
Community support for ART patients in the public sector represents a continuum that stretches from more formalized (even paid) community health workers (CHWs) to informal activities, including voluntary support groups for people living with HIV/AIDS (PLWHA) or members of their social networks who volunteer to act as ARV treatment buddies. The roles of these initiatives have broadened with time, but are generally oriented towards the care and support of PLWHA, rather than AIDS prevention or the promotion of health (Schneider et al., 2008). CHWs are multiskilled and multipurpose HIV/tuberculosis workers, involved in counseling, adherence support, and home-based care. Since their emergence, various tasks have shifted from health professionals to CHWs, including tracking drop-outs and supplying drug-readiness training (Schneider et al., 2008). Given the nature and magnitude of the HIV epidemic, it is increasingly important to empower ART patients to take responsibility for their own treatment, rather than relying on CHWs to enforce ART adherence. Consequently, patients are requested to identify a ‘treatment buddy’, usually someone living in their household, who is aware of the patient's status and who is willing to assist him/her with adherence issues. The treatment buddy attends education sessions, signs the consent to begin ART together with the patient, and reminds and supports the patient once ART has commenced (Coetzee, Hildebrand et al., 2004). Patient mobilization and empowerment also include the support of an AIDS patient by fellow PLWHA. Peer-support groups, which are generally not exclusively for patients on ART, facilitate the discussion of factors that may enhance or impede adherence, such as adverse events, disclosure, and other psychosocial issues, and also act as forums for health promotion and education.
Previous studies have identified the patient's characteristics, pre-ART health, and health literacy (educational level and knowledge about HIV/AIDS and ART) as predictors of ART outcomes (DART Virology Group and Trial Team, 2006, Hinkin et al., 2004, Kalichman et al., 2008, van Leth et al., 2005, Murphy et al., 2004, Nicastri et al., 2005, Wood et al., 2006). However, the published longitudinal research into the relationship between community support for ART patients and treatment outcomes is limited, especially in resource-limited settings (Burgoyne, 2005, MSF (Médecins Sans Frontières), 2006). This study aimed to extend the current literature by investigating how immunological and virological responses to ART, measured at three points in time (after six, 12, and 24 months of ART), are influenced by patient characteristics (age, sex), health literacy (educational level and knowledge about HIV/AIDS), baseline CD4 cell count, baseline viral load, and three forms of community support (treatment buddy, CHW, and HIV/AIDS support group) in a sample of 268 patients enrolled in the public-sector ART program of the Free State Province of South Africa (2004–2007). In addition, a series of open-ended questions was used to assess the contributory role of these community support initiatives in achieving durable ART success.
Section snippets
Setting
This study is part of an ongoing cohort study of patients enrolled in the public-sector ART program in the Free State Province of South Africa. This research was approved by the Ethics Committee of the Faculty of Humanities, University of the Free State, and authorized by the Provincial Department of Health.
Study population
The sampling frame consisted of a list of names, obtained from the Provincial Department of Health, of adult patients certified as medically ready to commence ART (CD4 < 200 cells/μL and/or WHO
Sample description
Table 1 shows the demographic characteristics and baseline health of our sample of 268 ART patients. It also describes the health literacy measures and the use of social capital initiatives over time. The patients' virological and immunological measures are also shown across time.
Overall, none of the 268 patients had both a CD4 cell count above 200 cells/μL and an undetectable viral load at the start of treatment. A descriptive analysis showed that after six months of ART, 46.1% of respondents
Discussion
This analysis of 268 patients, performed over the first two years of public-sector ART in one of the provinces of South Africa, shows that 76.4% of patients were classified as treatment successes (CD4 cell count ≥ 200 cells/μL and viral load < 400 copies/mL) after 24 months of ART. As many as 92.5% of patients responded at least partially to treatment after two years of ART. The survival rate was a staggering 88.4% during the first 24 months of treatment, with most deaths following very low baseline
Acknowledgements
We sincerely thank the patients in the ART program for their time and energy in sharing their views and experiences. This study was funded by the Research Foundation–Flanders; the International Development Research Centre of Canada; the Joint Economics, AIDS and Poverty Program (with the support of the Australian Agency for International Development; the United States Agency for International Development; the UK Department for International Development; the United Nations Development Program);
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