Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
Right to Care, Johannesburg, South Africa.
Health Res Policy Syst. 2021 Jan 6;19(1):2. doi: 10.1186/s12961-020-00673-y.
In September 2016, South Africa (SA) began implementing the universal-test-and-treat (UTT) policy in hopes of attaining the UNAIDS 90-90-90 targets by 2020. The SA National Department of Health provided a further directive to initiate antiretroviral therapy (ART) on the day of HIV diagnosis in September 2017. We conducted a qualitative study to determine the progress in implementing UTT and examine health providers' perspectives on the implementation of the same-day initiation (SDI) policy, six months after the policy change.
We conducted in-depth interviews with three professional nurses, and four HIV lay counsellors of five primary health clinics in the Gauteng province, between October and December 2017. In September 2018, we also conducted a focus group discussion with ten professional nurses/clinic managers from ten clinic facilities. The interviews and focus groups covered the adoption and implementation of UTT and SDI policies. Interviews were conducted in English, Sotho or Zulu and audio-recorded with participant consent. Audio-recordings were transcribed verbatim, translated to English and analysed thematically using NVivo 11.
The data indicates inconsistencies across facilities and incongruities between counsellor and nursing provider perspectives regarding the SDI policy implementation. While nurses highlighted the clinical benefits of early ART initiation, they expressed concerns that immediate ART may be overwhelming for some patients, who may be unprepared and likely to disengage from care soon after the initial acceptance of ART. Accordingly, the SDI implementation was slow due to limited patient demand, provider ambivalence to the policy implementations, as well as challenges with infrastructure and human resources. The process for assessing patient readiness was poorly defined by health providers across facilities, inconsistent and counsellor dependent. Providers were also unclear on how to ensure that patients who defer treatment return for ongoing counselling.
Our results highlight important gaps in the drive to achieve the ART initiation target and demonstrate the need for further engagement with health care providers around the implementation of same-day ART initiation, particularly with regards to infrastructural/capacity needs and the management of patient readiness for lifelong ART on the day of HIV diagnosis. Additionally, there is a need for improved promotion of the SDI provision both in health care settings and in media communications to increase patient demand for early and lifelong ART.
2016 年 9 月，南非（SA）开始实施普遍检测和治疗（UTT）政策，希望到 2020 年实现联合国艾滋病规划署 90-90-90 目标。南非国家卫生部于 2017 年 9 月发布了进一步指令，要求在 HIV 诊断日开始抗逆转录病毒治疗（ART）。我们进行了一项定性研究，以确定实施 UTT 的进展情况，并检查卫生服务提供者对实施同日启动（SDI）政策的看法，这是政策变化六个月后的情况。
我们于 2017 年 10 月至 12 月期间，在豪登省的五家初级保健诊所对三名专业护士和四名艾滋病毒外展顾问进行了深入访谈。2018 年 9 月，我们还与十家诊所设施的十名专业护士/诊所经理进行了焦点小组讨论。访谈和焦点小组涵盖了 UTT 和 SDI 政策的采用和实施。访谈以英语、索托语或祖鲁语进行，并在参与者同意的情况下进行录音。录音被逐字转录、翻译成英语，并使用 NVivo 11 进行主题分析。
数据显示，各设施之间存在不一致之处，顾问和护理提供者对 SDI 政策实施的看法也存在差异。虽然护士强调了早期开始 ART 的临床益处，但他们担心立即开始 ART 可能对一些准备不足且可能在接受 ART 初始治疗后很快就不再参与治疗的患者来说是压倒性的。因此，由于患者需求有限、提供者对政策实施犹豫不决，以及基础设施和人力资源方面的挑战，SDI 的实施进展缓慢。各设施的卫生提供者对患者准备情况的评估过程定义不明确、不一致且依赖顾问。提供者也不清楚如何确保推迟治疗的患者返回接受持续咨询。
我们的研究结果突出了实现 ART 启动目标方面的重要差距，并表明需要进一步与卫生保健提供者就同日开始 ART 进行接触，特别是在基础设施/能力需求以及管理患者对 HIV 诊断当天终生接受 ART 的准备方面。此外，需要在卫生保健环境和媒体宣传中进一步宣传 SDI 服务的提供，以增加患者对早期和终生 ART 的需求。
