Search

Background: Since 2019, the World Health Organization has recommended dolutegravir-containing regimens for HIV in low- and middle-income countries because of its high genetic barriers to resistance, lower drug interactions, fewer side effects, higher viral load (VL) suppression rates and cost-effectiveness compared to efavirenz. Objectives: This study investigates factors associated with unsuppressed VLs in people living with HIV on tenofovir-lamivudine and dolutegravir (TLD) in South Africa (SA). Method: A cross-sectional study was conducted between October 2023 and February 2024 at Mamelodi Regional Hospital’s Ntshembo Clinic. Participants were people living with HIV aged 18 years and older, more than 6 months on TLD, with either suppressed (≤ 50 copies/mL) or unsuppressed ( 50 copies/mL) VLs. Results: Significant associations were found between unsuppressed VL and factors such as sex, marital status, occupation and education level. Male participants were less likely to achieve VL suppression than female participants (odds ratio: 0.45, p = 0.0007). Poor antiretroviral therapy adherence was linked to higher unsuppressed VL (p 0.05). Newly initiated patients had significantly lower suppression rates (p 0.05). The use of traditional or herbal and religious products was also linked to unsuppressed VL (p 0.05). Conclusion: The study highlights the importance of addressing adherence factors to improve VL suppression rates among people living with HIV on TLD. Contribution: Tailored interventions targeting adherence, especially among newly initiated patients, and addressing the use of traditional or herbal and religious products are warranted to enhance treatment outcomes.

Background: Community health workers (CHWs) play an important role in health promotion through health campaigns and home visits, and provide linkage to care and support patient management. In the informal settlements, CHWs identify health challenges and help residents to access healthcare facilities. Aim: This study aimed to explore the perception held by the community members regarding CHWs’ contribution to health promotion in Melusi informal settlements within the Tshwane district. Setting: The study was conducted in Melusi informal settlement situated in Pretoria west in South Africa. Methods: Descriptive exploratory qualitative research methods were used, with open and closed-ended questions during individual interview sessions. Participants were purposefully selected in collaborating with the community leaders and using CHWs’ data to identify individuals with direct interaction with CHWs. Results: Participants praised CHWs’ communication skills, engagement strategies, and ability to provide valuable health services. Community members expected CHWs to provide healthcare services, educational support, advocacy for health issues and guidance on well-being. Barriers such as community resistance, a lack of privacy and difficulties in reaching households were noticed. However, CHWs were commended for their impact on well-being, offering health services, emergency support, food assistance and improved healthcare accessibility. Conclusion: The study indicates that community members have positive perceptions of CHWs. This highlights the significant role of CHWs in promoting health and well-being within the community. Contribution: This study provides insights into community perceptions of CHWs in informal settlements, emphasising their impact on community well-being. It provides a basis for their effectiveness and support in delivering health services in the informal settlement.

Background: South Africa’s health care system grapples with persistent challenges, including health care provider shortages and disparities in distribution. In response, the government introduced clinical associates (Clin-As) as a novel category of health care providers. Aim: This study mapped Clin-As’ history and practice in South Africa, assessing their roles in the health workforce and offering recommendations. Methods: Following the framework outlined by Arksey and O’Malley, we conducted a comprehensive literature search from January 2001 to November 2021, utilising PubMed, Scopus and EBSCOhost databases. One thousand six hundred and seventy-two articles were identified and then refined to 36 through title, abstract and full-text screening. Results: Strengths of the Clin-A cadre included addressing rural workforce shortages and offering cost-effective health care in rural areas. Challenges to the success of the cadre included stakeholder resistance, rapid implementation, scope of practice ambiguity, inadequate supervision, unclear roles, limited Department of Health (NDoH) support, funding deficits, Clin-As’ perceived underpayment and overwork, degree recognition issues, inadequate medical student training on Clin-A roles, vague career paths and uneven provincial participation. Conclusion: As a health care provider cadre, Clin-As have been welcomed by multiple stakeholders and could potentially be a valuable resource for South Africa’s health care system, but they face substantial challenges. Realising their full potential necessitates enhanced engagement, improved implementation strategies and precise scope definition. Contribution: This study acknowledges Clin-As in SA as a promising solution to health care workforce shortages but highlights challenges such as stakeholder resistance, insufficient NDoH support and unclear policies, emphasising the need for comprehensive efforts to maximise their potential.

Background: Only 66% of South African people living with HIV (PLWH) are virologically suppressed. Therefore, it is important to develop strategies to improve outcomes. Objectives: Assess the effect of interventions on 12-month retention in care and virological suppression in participants newly initiated on antiretroviral therapy. Method: Fifty-seven clinics were randomised into four arms: Ward-based primary health care outreach teams (WBPHCOTs); Game; WBPHCOT–Game in combination; and Control (standard of care). Sixteen clinics were excluded and four re-allocated because lay counsellors and operational team leaders failed to attend the required training. Seventeen clinics were excluded due to non-enrolment. Results: A total of 558 participants from Tshwane district were enrolled. After excluding ineligible participants, 467 participants were included in the analysis: WBPHCOTs (n = 72); Games (n = 126); WBPHCOT–Games (n = 85); and Control (n = 184). Retention in care at 12 months was evaluable in 340 participants (86.2%) were retained in care and 13.8% were lost to follow-up. The intervention groups had higher retention in care than the Control group, but this only reached statistical significance in the Games group (96.8% vs 77.8%; relative risk [RR] 1.25; 95% confidence interval [CI]: 1.13–1.38; P = 0.01). The 12 month virologic suppression rate was 75.3% and was similar across the four arms. Conclusion: This study demonstrated that an adherence game intervention could help keep PLWH in care. What this study adds: Evidence that interventions, especially Games, could improve retention in care.

Background: In 2016 the Gauteng Department of Health engaged University of Pretoria Family Medicine to provide` education, training and information and communication technology support for the phased scale-up of ward-based outreach teams (WBOTs) through community-oriented primary care (ICT-enabled COPC). As in all service delivery, quality assurance is essential. In contemporary best practice, it brings together peer-to-peer learning and quality improvement (QI) in what is termed here as peer-learning reviews (PLRs). Aim: To assess implementation fidelity and assure the quality of community-based healthcare services. Setting: This study was conducted in two districts of Gauteng province, South Africa. Methods: A 3-day PLR of paired WBOTs was conducted by multi-disciplinary teams of academics, partners and site-selected healthcare practitioners. Guided by a benchmark survey distilled from the seven COPC practice elements, they conducted individual interviews, accompanied WBOT members in field and facilitated solution-focused peer exchange workshops with all participants. Results: At all sites there was clear evidence of achievements and practical challenges with respect to mapping; support, networks and partnerships; infrastructure and functional equipment; work integrated learning; data and service activities; and performance status and management. Methodologically, PLRs supported inclusive, context-specific learning for all along the healthcare service pathway. They generated action plans derived from shared understanding and joint decision-making. Conclusion: The PLRs and the implementation results demonstrate the importance of structuring learning into service and research. Both helped develop participants’ abilities to understand what they do, do their work, grow their sense of self-worth and improve their relationship with others.

Little is known about the barriers and benefits of home-based HIV services offered by community health workers. These are especially important as the South African government embarks on scaling up community-based health services, which include HIV care. This study set out to understand potential benefits and barriers of these services in Tshwane district and develop recommendations for improvement. From June to August 2019, seven focus group discussions were conducted with 58 participants: four with 36 ward-based outreach team (WBOT) members and three with 22 people living with HIV (PLWHIV). Three aspects of care were explored: 1. Experience of performing, receiving or observing home-based HIV care; 2. Barriers to conducting home visits; and 3. The perceived value of WBOTs and home-based HIV care. While home-based HIV care was seen as a support strategy which could motivate patients to take their medication, the unpredictability of patients' responses to HIV test results, incorrect addresses (driven by the need for identity documents), fear of stigma through association with WBOTs, especially those in uniform, little or no preparation of patients for home-based care, and lack of confidentiality and trust were raised as potential barriers. To successfully implement effective home-based HIV care in South Africa, perceived barriers should be addressed and recommendations offered by people providing and receiving these services should be seriously considered. Pertinent recommendations include integrating WBOTs into clinics and existing support structures, improving training on confidentiality and HIV testing, and rethinking the recruitment, scope of work and safety of WBOTs. In addition, research should be conducted into the impact of the requirements for identity documents and community health worker uniforms.

Voluntary medical male circumcision (VMMC) reduces the acquisition of human immunodeficiency virus (HIV) in heterosexual men by up to 60%. One HIV infection is averted for every 5 to 15 VMMCs. To conduct VMMCs in large populations, large numbers of trained healthcare professionals are needed. Countries in Sub-Saharan Africa have a high burden of HIV and a shortage of healthcare professionals, creating a healthcare conundrum. To bridge this gap, South Africa launched a new cadre of mid-level medical worker called Clinical Associates (CA). We assessed the ability of CAs to perform circumcisions of adequate quality and their subsequent usefulness to meet the demands of VMMCs in a population with a high HIV burden.We conducted a retrospective analysis, reviewing patient files (n = 4850) of surgical VMMCs conducted over a 16-month period. Patient files were sourced from clinics and hospitals that provided free VMMCs in Tshwane district in South Africa.Clinical associates performed 88.66% of the circumcisions and doctors performed the remaining 11.34% (p < 0.001). The number of adverse events did not differ between the two groups. Data on intra-operative adverse events were available for 4 738 patients. Of these, 341 (7.2%) experienced intra-operative adverse events. For the whole sample, 44 (8.1%, n = 543) adverse events occurred during circumcisions done by doctors and 297 (7.1%, n = 4195) occurred during circumcisions done by CAs (p = 0.385). Clinical associates performed circumcisions in shorter times (duration: 14.63 minutes) compared to doctors (duration: 15.25 minutes, t = -7.46; p < 0.001). Recorded pain, bleeding, swelling, infection and wound destruction did not differ between clients circumcised by CAs and doctors. This study is limited by the use of data from a single district.Clinical associates contribute to the demands for high numbers of VMMCs in Tshwane district, South Africa. Clinical associates perform VMMCs at a clinical standard that is comparable to circumcisions performed by doctors.