South Africa: Solving treatment bottlenecks

MTHATHA, 4 January 2008 (PLUSNEWS) - The monthly "Improvement Meeting" at Qumbu Health Centre, 50km from the Eastern Cape province town of Mthatha, is supposed to start at 9am, but rarely starts before 10am.

Many of the nurses attending work at remote rural clinics scattered across Mhlontlo District and have to travel along rudimentary roads using the mini-bus taxis system to reach the meeting, so no-one complains about late arrivals.

Once seated, they begin calling out figures to Kholeka Mhlakaza, the HIV/AIDS treatment programme manager for Mhlontlo, who writes them on a whiteboard.

The figures reflect how many patients at each clinic have begun antiretroviral (ARV) treatment in the past month as well as how many suspected TB patients and children born to HIV positive mothers have been tested for HIV.

Although the numbers look deceptively modest, what they represent is an extradorinary achievement for a district where only three doctors provide HIV care for 200,000 residents, an estimated 25,000 of whom are HIV positive, and where only 75 patients were initiated on ARVs in the first eight months after treatment began rolling out here in July 2004.

Today, about 1,600 patients are receiving ARVs, with an average of about 60 new patients beginning ARV treatment each month. The story of how Mhlontlo District achieved this without any significant increase in resources is one that South Africa needs to learn from.

South Africa's minister of health, Dr Manto Tshabalala-Msimang, regularly describes the country's ARV programme as the largest in the world (about 370,000 people were on treatment as of September 2007), but others point out that with the world's largest burden of HIV infections, treatment scale-up is still happening too slowly.

In a recent presentation, Dr Andrew Boulle, a public health specialist from the University of Cape Town, said that in South Africa's Free State Province, 87 percent of HIV-patients who died during a 20-month period had never received ARVs.

Many HIV-positive South Africans are not coming forward for testing and treatment, but others are dying while waiting for ARV treatment to begin.

An untapped resource

The bottlenecks preventing people from starting treatment were the same in Mhlontlo District as they are in much of the country - too few doctors and pharmacists at too few treatment sites.

While staff at the sites accredited to provide ARV treatment struggled to cope with high workloads and patients living in remote areas struggled to reach them, nurses at 22 primary health-care clinics dotted throughout the district were, according to Cathy Green, a project manager with the Massachusetts-based non-profit organisation, Institute for Healthcare Improvement (IHI), "a huge untapped resource".

"The biggest barrier to initiation was simply being able to access the facilities where the doctors were," Green told IRIN/PlusNews. "All the preparation for ARVs was being done at four sites and people just couldn't afford the transport to go there repeatedly."

Only doctors can initiate patients on ARVs in South Africa, but with proper training, nurses are capable of monitoring treatment and distributing monthly prescriptions.

In March 2005, IHI, in partnership with the local health department and the Regional Training Centre at Walter Sisulu University in Mthatha, began training nurses at Mhlontlo's clinics in how best to manage their limited resources to treat patients infected with HIV.

Most pre-ARV care and preparations for treatment are now carried out by nurses at clinics, meaning that treatment initiations often only require one visit to the hospital or health centre to see a doctor, while in some cases doctors visit the clinics to initiate treatment.

Meanwhile, patients who were previously receiving ARVs at the larger health centres and hospitals are now being referred back to their local clinics for chronic care.

Alice Sodinga, a nurse working at Mhlontlo District's Nessie Knight Hospital - where 149 of their 156 patients on ARVs have been referred back to local clinics for chronic HIV care - told IRIN/PlusNews: "Now they [the patients] are very comfortable, it saves them money in transport. And there is time now for us to go to our people, to visit the wards and to do community outreach."

Creative solutions

The transition has not been without challenges. In the face of unreliable electricity and water supplies, the difficulties of transporting samples and a lack of space and essential supplies, clinic staff are encouraged to come up with creative solutions and try them out on a small scale before sharing the results at monthly meetings like the one at Qumbu Health Centre.

Ndenze Ntutu, a local clinic nurse, said one of the ideas her clinic had successfully tested was the use of community healthcare workers to do pre and post-test counselling for HIV testing and to follow up treatment defaulters.

"The meetings help us gather ideas like this and correct mistakes," she said.

The whiteboard that HIV/AIDS treatment programme manager, Mhlakaza, painstakingly records on, is part of a drive to track the impact of innovations through good record-keeping. "Without data, you're working in the dark," Green said. "How do you know the changes are making a difference?"

Staff at one hospital, for example, theorised they would be able to increase the number of inpatients they tested for HIV if they simply changed their working hours slightly. After tracking the numbers for a month, they determined the experiment was a success.

"When ART (antiretroviral therapy) was originally introduced, many healthcare workers assumed that the guidelines available to them were rules that had to be followed to the letter, even when they didn't make sense in their local context," said Green.

Encouraging nurses to interpret and adpat these guidelines to local realities, Green said, has enabled them to come up with solutions to overcome treatment bottlenecks.

The monthly meetings also provide an important opportunity for trouble-shooting. At a recent meeting in Qumbu, Green asked clinic staff to explain why there were a number of "medically eligible" patients who had not yet started treatment. It soon emerged that many of them were simply waiting to be seen by a doctor.

"Do we know when the doctor is coming? Those clients are at risk," Green asked.

"We're waiting for a date from the hospital," responded a clinic nurse. A staff member from the hospital explained the problem was the transport to bring the doctor to the clinics: "We only have one van and one driver," she said.

"The content of meetings often ends up dealing with very practical constraints that impede treatment," said Green later. "Like the lack of transport - you can pick up those kinds of problems and the [local health authority] people are there to help address it."

A replicable model?

A number of studies have supported the importance of moving towards more nurse-led, decentralised ARV treatment programmes such as the one being used in Mhlontlo, so as to not only increase the numbers of patients on treatment but the numbers who stay on treatment.

A report by international humanitarian agency Médecins Sans Frontières (MSF) on the scale-up of treatment in Eastern Cape's Lusikisiki District found that whereas 19 percent of patients who accessed treatment at a central hospital defaulted in their first 12 months on treatment, only two percent of those receiving treatment at local clinics did so.

Only South Africa's health department can take the Mhlontlo model and replicate it on a large scale, but IHI is helping to implement similarly impressive ARV treatment scale-ups in several other districts around the country. The goal, said Green, was always to find local partners who can eventually take over managing the improvement of ARV programmes and sustain the rate of progress.

Green believes that meeting the ambitious new treatment targets set by the National Strategic Plan for HIV and AIDS, which South Africa adopted in 2007, will depend on a willingness to try new approaches and to consider locally-designed solutions to treatment barriers.

"Often we can't increase resources, so most of the time we're working to try and improve systems," Green said. "Even where resources are more plentiful, those resources will eventually be inadequate so we need alternative models."

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See also, PlusNews In-Depth: South Africa - The world's biggest ARV programme?

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