Objective To assess the quality of pre-antiretroviral therapy (ART) care in Cape Town and its continuity with HIV counselling and testing (HCT) and ART.
Methods The scale-up of the HCT, pre-ART and ART service platform and programmatic support in Cape was described. Data from the August 2010 routine annual HIV/TB/STI evaluation, which included interviews with 133 facility managers and folder reviews of 634 HCT clients who tested positive and 1115 clients receiving pre-ART HIV care, were analysed.
Results Historically, the implementation and management of pre-ART care has been relatively neglected compared with the scale-up of HCT and ART. CD4 counts were carried out for 77.5% of positive HCT clients, and 46.6% were clinically staged – crucial steps that determine the care path. There were gaps in quality of care (32.2% of women had a PAP smear), missed opportunities for integrated care (67% were symptomatically screened for tuberculosis) and positive prevention (48.3% had contraceptive needs assessed). Breaks in the continuity of care of pre-ART clients occurred with only 47.2% of eligible clients referred appropriately to the ARV service.
Conclusion While a package of pre-ART care is clearly defined in Cape Town, it has not been fully implemented. There are weaknesses in the continuity and quality of service delivered that undermine the programme objectives of provision of positive prevention and timely access to ART.
Objectif: Evaluer la qualité des soins preART à Cape Town et leur continuité avec le conseil et test VIH (HCT) et l’ART.
Méthodes: Afin de décrire le déploiement de la plate-forme des services HCT, preART et ART et l’appui programmatique à Cape Town, les données annuelles de l’évaluation de routine en août 2010 du VIH/TB/IST, de l’entretien avec 133 responsables de services et un examen des dossiers de 634 HCT qui ont testé positif et 1115 patients recevant des soins preART du VIH ont été analysés.
Résultats: Historiquement, l’implémentation et la gestion des soins preART ont été relativement négligées par rapport au déploiement de l’HCT et de l’ART. Le dosage des CD4 a été effectué pour 77,5% des patients HCT positifs et 46,6%étaient cliniquement pris en charge - étapes cruciales déterminant la piste des soins. Il y avait des lacunes dans la qualité des soins (32,2% des femmes ont eu un frottis PAP), des occasions manquées pour des soins intégrés (67% ont été symptomatiquement dépistés pour la tuberculose) et la prévention positive (48,3% avaient besoins d’une évaluation de contraception). Des ruptures dans la continuité des soins preART pour les patients sont survenues avec seulement 47,2% des patients éligibles référés convenablement au service ARV.
Conclusion: Même si un ensemble de soins preART est clairement défini à Cape Town, il n’a pas été complètement implémenté. Il y a des faiblesses dans la continuité et la qualité des services délivrés qui minent les objectifs du programme pour la fourniture de la prévention positive et un accès opportun à l’ART.
Objetivo: Evaluar la calidad de los cuidados preTAR en Ciudad del Cabo y su continuidad con el aconsejamiento y prueba (APV) del VIH y el TAR.
Métodos: Con el fin de describir el aumento a escala del APV, pre TAR y los servicios de la plataforma de TAR, y el apoyo programático en Ciudad del Cabo, se analizaron datos de la evaluación rutinaria anual para el VIH/TB/ITS realizada en Agosto 2010, de entrevistas con 133 gestores de centros sanitarios y una revisión de sobre papel de 634 APVs que dieron positivos y de 1115 clientes recibiendo cuidados para VIH.
Resultados: Históricamente, la implementación y el manejo de los cuidados preTAR han estado relativamente olvidados en comparación con el aumento a escala del y el TAR. Los conteos de CD4 se realizaron para el 77.5% de los clientes que dieron positivos durante el APV y un a 46.6% se les determinó el estadio clínico – pasos cruciales que determinan el camino a seguir. Había diferencias en la calidad de los cuidados (un 32.2% de las mujeres tenían una prueba de Papanicolau); oportunidades perdidas para realizar un cuidado integrado (al 67% se les realizó un cribaje sintomático para la TB) y prevención positiva (en un 48.3% se evaluó sus necesidades de anticonceptivos). Las interrupciones en los cuidados preTAR ocurrió con solo un 47.2% de los clientes que habían sido referidos apropiadamente a los servicios de APV.
Conclusión: Aunque en Ciudad del Cabo se tiene un paquete de cuidados preTAR claramente definido, no se ha implementado totalmente. Hay debilidades en la continuidad y la calidad del servicio entregado que minan los objetivos del programa y la entrega de una prevención positiva y de un acceso a tiempo del TAR.
Increasing access to effective HIV interventions is a priority in sub-Saharan Africa (WHO 2009) where, in 2008, an estimated 22.4 million people were living with HIV and 1.9 million were newly infected (UNAIDS 2009). Since early 2003, the scaling-up of provision of antiretroviral therapy (ART) has been a key programmatic goal, initially spear-headed by the WHO 3 by 5 initiatives (WHO 2003) and subsequently under the banner ‘Towards Universal Access’ (WHO 2009). The latter promotes country-driven processes within existing national AIDS strategies and prioritises the expansion of positive prevention and care for people living with HIV in addition to antiretroviral (ARV) treatment. Positive prevention targets HIV-positive individuals to reduce behaviours associated with HIV transmission (King-Spooner 1999). A meta-analysis of controlled trials found it to be efficacious in routine care settings when integrated with medical care and addressing health, behaviour and well-being (Crepaz et al. 2006) and applicable in the African context (Bunnell et al. 2006). Positive prevention is supported by recent WHO guidelines (O’Reilly 2008) on effective, evidence-based interventions for people living with HIV in resource-limited settings for whom ART is not yet clinically indicated, i.e. ‘pre-ART care’.
This article describes the Cape Town experience of implementing pre-ART care, assesses the effectiveness of this care and describes the extent of its integration with ART care in public primary care facilities in the district. Cape Town has a population of over 3 million and an antenatal HIV prevalence of 18.3% (PGWC 2009). We document breaks in the continuum between HIV counselling and testing (HCT), pre-ART and ART services. Access to HIV care by women using prevention of mother-to-child transmission (PMTCT) services is not evaluated as not all antenatal provision sites were reviewed.
We describe the service delivery platforms for HCT, pre-ART and ART in Cape Town and key elements of programmatic support from the perspective of participant authors (KJ and VZ) who were district programme managers.
An evaluation tool was used to assess the effectiveness of care in each facility and information aggregated at a subdistrict and district level. Evaluation tools to assess the programme effectiveness and quality were first developed in 2003 and refined annually (Scott et al. 2010). These are based on an evaluation framework proposed by UNICEF and the WHO (2001) for the evaluation of PMTCT programmes describing measurable components of programme effectiveness (Knippenberg 1986). In our modified framework, these conditions are as follows: access to the target population; availability of key resources and capacity; quality of care; integrated care [HIV/tuberculosis (TB)/sexually transmitted infection (STI)/Reproductive Health] and continuity of care.
The 2010 audit
In August 2010, data were collected on the HCT and pre-ART services as part of the routine annual HIV/TB/STI evaluation carried out in Cape Town. Subdistrict TB HIV coordinators organised and led the audit teams, and team members included facility and local programme managers. Audits were preceded by a routine half-day of tool training and planning the audit logistics. In some subdistricts, coordinators involved facility managers in self-audit as part of a quality improvement process. In other subdistricts, facility managers did not audit their own facilities, as it was felt that their involvement in the team might alter the accuracy and objectivity of the results.
Routine data, collected in facility-based registers and collated at district level, were drawn from management data systems. Audit teams visited facilities over a period of 1 month. It took approximately 3 h to interview the facility manager, assess the equipment in consulting and counselling rooms and do a set of HCT, pre-ART, ART, STI and TB folder reviews. Non-probability sampling was carried out, with 10 folders sampled from each facility for each programme. Gathering data from 40 folders is achievable annually by local service managers and enables all facilities to engage with their data in a participatory quality improvement process, the main objective of information collection. HCT folders were sampled from the HCT register starting at a date 1 month before the audit and working backwards to select five HIV-positive and five HIV-negative patients seen over the preceding month. Ten pre-ART folders were similarly sampled from the HCT register with the additional criterion that the patients had to have attended at least two clinical visits after their HIV diagnosis. Denominators used in calculating indicators vary as clients are excluded if the question does not apply to them (e.g. contraception is not applicable to HIV-positive children) and where there are missing data.
Facility data were entered in Excel spreadsheets and imported into STATA® version 9 for calculations of district proportions and confidence intervals for sampled data. Because proportional sampling had not been carried out, it was necessary to introduce weighting factors. Data from the HCT folder reviews were weighted by the district proportion of HCT clients counselled in each facility. Data from the pre-ART folder reviews were weighted against the district proportion of HCT clients diagnosed positive in each facility.
HIV services in Cape Town.
Historically, the implementation and management of routine pre-ART HIV care has been relatively neglected, falling in the gap between the successful scale-up of initially HCT and then ART. The expectation of the HIV programme was that HCT is the entry point to the HIV services and that positive clients would be held in care receiving a package of prevention and care with regular monitoring until eligible for ART. The implementation of this continuum in Cape Town is described in Figure 1.
Locally defined clinical guidelines exist, but service models for implementation of guidelines do not. Pre-ART services include a set of prevention, early detection and treatment activities (Figure 2) and are provided at most public primary care facilities. Facility managers are responsible for implementing the delivery of pre-ART services with little programmatic support. There is little routine health information on the quality and effectiveness of pre-ART care. Possible models of care were not included in policy making, and resources were not added. Existing staff were trained to deliver care. In some facilities, there are dedicated HIV clinics with trained staff, while in others, the general outpatient service offers HIV care in addition to other care. Approximately two-thirds of facilities are run by the local authority and are nurse driven with doctor support, while in provincially managed facilities, both nurses and doctors provide first-line care.
HIV counselling and testing is provided within all public primary care facilities. However, ART has been delivered at a subset of accredited sites. The scale-up of HCT and ART was driven by provincial and district managers in response to analyses of local need and national directives. Additional funding for HCT was allocated for counsellors and rapid test kits and staff, drugs and monitoring and evaluation systems were allocated for ART services.
The 2010 assessment.
The full audit was conducted in 133 public primary-level facilities in Cape Town, all of which offered HCT. Only 123 facilities offered pre-ART care (midwife obstetrical services and youth centres did not), and 122 of these were audited (99%) for pre-ART care. All 133 facility managers were interviewed and gave information on the training of 1307 clinical staff. Folder reviews were conducted using records of 634 clients found to be positive at HCT –‘HCT clients’– and using records of 1115 known HIV clients attending for pre-ART care –‘pre-ART clients’. Five hundred and twenty-five (47%) of these pre-ART clients were eligible for ART.
Table 1 lists key audit indicators for 2010. Access to pre-ART care depends on both access to an HIV diagnosis and continuity between HCT and pre-ART services. The uptake of HCT was 456 145 (17.8% of the adult population). While the location of HCT within the same facilities providing pre-ART care should facilitate access, 77.5% of positive HCT clients had a CD4 count and only 46.6% were clinically staged. CD4 testing takes place on the same day as HIV testing but staging takes place in pre-ART care. Both assessments determine the care path of HIV-infected clients.
Table 1. Assessment of quality of pre-ART care and its continuity with HCT and ART
The annual HCT uptake has as its numerator the number of clients tested, and the denominator is the adult population over 15 years.
ARV, antiretroviral; ART, antiretroviral therapy; HCT, HIV counselling and testing; PAP, papanicolaou test; STI, sexually transmitted infection; TB, tuberculosis
*N/A as population was not sampled; entire adult population, staff complement or total public primary care facilities included.
Routine register and population data
% Annual HCT uptake (adults >15 years HIV tested)
17.8% (2 729 297)
HCT folder review
% Positive HCT clients with CD4 counts
% Positive HCT clients clinically staged
Facility manager interview
% Facilities offering daily pre-ART HIV services
Availability of key resources and staff capacity
Facility manager interview
% Clinical staff trained in pre-ART care
% Facilities with stock outs of cotrimoxazole
% Facilities with functional stock control mechanisms for a basket of HIV/TB/STI items
Quality of care
Pre-ART care folder review
% Clients with notes on the customised HIV stationery
% Clients evaluated for social assistance
% Clients with PAP smear (women only)
% Clients with symptomatic TB screen and appropriate follow-up at last visit
Extent of positive prevention strategies
Pre-ART care folder review
% Clients with contraceptive needs assessed (men and women) at last visit
% Clients with symptomatic STI screen and appropriate follow-up at last visit
% Clients with condoms issued at their last visit
Continuity of care
Pre-ART care folder review
% Clients clinically staged at last visit
% Clients with CD4 monitoring according to protocol
% Clients with a management plan noted at last visit
% Clients eligible for ARVs referred appropriately
Two-thirds of clinical staff (professional nurses and doctors) were trained in pre-ART care; 82% of facilities had functional stock control mechanisms for a basket of tracer HIV/TB/STI drugs, and a minority of clinics – 4.5%– experienced drug stock outs in the last 6 months.
Evaluation of quality of care was defined as adherence to the current local service guidelines. We found important gaps. Only 50.1% of clients were evaluated for social assistance, and 32.2% of women had ever had a papanicolaou test (PAP smear) done. There were missed opportunities for integrated care with 67.2% being symptomatically screened for tuberculosis at their last clinic visit. There were missed opportunities for positive prevention in the care received: only 48.3% of clients had their contraceptive needs assessed, 61.2% were screened symptomatically for sexually transmitted infections, and 42.5% were issued with condoms at their last clinic visit.
Breaks in the continuity of care occurred in pre-ART service delivery: management plans were noted in only 63.9% of HIV-infected patients accessing care. This compromises continuity of care in a context where patients are often seen by different clinicians. We found that patients were not monitored optimally for eligibility for ART (45.7% of pre-ART patients were staged clinically, and 88.5% had their CD4 count measured according to the current protocol). Furthermore, only 47.2% of patients who were monitored and found to be eligible for ART were referred appropriately to an ART service point. ART mostly functions as a separate referral service within the primary care setting.
Timely health information is an essential management tool to deliver an effective service, particularly during the early phases of programme implementation. The HIV programme, with its component services of HCT, PMTCT, ART and care of co-infected TB patients, has an extensive set of data elements and indicators collected through different registers. While information assists in successfully managing the programme, registers create substantial administrative work (Jacucci et al. 2006; Nadol et al. 2008) within a health system that is already stretched (Coovadia et al. 2009; Steyn et al. 2008). Introducing yet another register to collect routine data on the care of patients diagnosed HIV positive would be ill-advised as these data are best suited to cohort analysis and are an onerous form of data collection and analysis. The evaluation of pre-ART care in the Cape Metropole shows that regular periodic audits are an attractive alternative. Audits provide a comprehensive snapshot and are especially useful for assessing inputs and processes – important components of a health information system at local level (AbouZahr & Boerma 2005). Audits have the added advantage of creating the opportunity to engage subdistrict managers and facility staff in a quality improvement process that can be linked to operational plans within the facility and subdistrict.
This evaluation shows a break in the continuum of care between HCT and ART and supports the similar finding of Kranzer et al. (2010), who followed up a sample of HIV-infected clients attending primary care services in a peri-urban community in Cape Town. They found that only 62.6% attended for a CD4 count measurement within 6 months of testing HIV positive; one-third of individuals with timely CD4 counts were eligible for ART, and two-thirds of those were successfully linked to ART care. This break in continuity is likely to contribute to the problem of late presentation and initiation on ART described by Bekker et al. (2006), despite the high HCT uptake. Low CD4 counts on ART initiation are associated with high early mortality (Lawn et al. 2006, 2008). This could be improved by careful management of pre-ART services upstream with attention to continuity, quality and retention in care.
The break in the continuity of care between HCT and the ART service highlights the danger of parallel implementation of component HIV services and the need to facilitate patient referral between members of teams and across the continuum of care. Vertical and horizontal models of service delivery have been the focus of much debate in the literature (Travis et al. 2004; Coovadia & Hadingham 2005). While vertical models of implementation of ART offer initial programme advantages such as close management and quality assurance, disadvantages are now emerging. Our evaluation shows that, while there are close working relationships between programme components, fragmentation persists which impacts negatively on patient care with leakages from the system. The service delivery platform supports a smooth transfer of clients from HCT service to pre-ART, but vertical orientation persists, perhaps because different health cadres are involved. Until 2010, HCT was lay counsellor driven while pre-ART was nurse and doctor driven and guideline development and training focussed on specific components with little attention to how they fit together. Health workers need to see their role in relation to the team and within a continuum of care, which could be addressed through improved training, mentorship and supervision. New and existing models of service delivery must be adapted to support client care across the full continuum.
The field of maternal, newborn and child health, while not addressing all the health needs of women, has begun to recognise the programmatic advantages of a continuum of care, conceptualising how it would work and assessing the effectiveness of a combination of interventions (WHO 2005; PMNCH 2006; Mangiattera et al. 2006; Bhutta et al. 2008; Kerber et al. 2007). The continuum of care is understood to work across time and place to avoid fragmentation or duplication of services, provide care for mothers and children, delivering comprehensive services rather than focussing on single health issues. These approaches have much to offer the design of HIV programmes, particularly with the current quest to integrate PMTCT programmes within the rest of HIV services, and HIV treatment services within maternity services. Research has shown that high loss to follow up occurs post-delivery of women who are started on ART as part of the PMTCT programme (Kaplan et al. 2008). The prevention and therapeutic health needs of HIV-positive men, women and children across the life cycle need to be addressed through services that retain clients in appropriate care.
We found that opportunities for HIV prevention interventions in pre-ART services were being lost, particularly in relation to positive prevention. Proportions of patients who received support promoting safer sex practices, sexual health and reproductive health choices were low. This demonstrates the divide between prevention and care interventions: prevention is neglected within the clinical context and is seen as separate from therapeutic care activities. In much of the HIV literature, ‘care’ is synonymous with ART.
We have presented the Cape Town experience as an urban case study of some of the problems encountered in the scale-up of pre-ART HIV care. Cape Town is perhaps not typical in that it has more financial, supervisory and management resources than many other districts in South Africa. But in identifying problems within a better-resourced programme, we probably err on the side of underestimating the extent of the problems elsewhere. Pilot work in a rural area in KwaZulu-Natal reveals similar programme challenges in delivering quality pre-ART care (personal communication Marian Loveday 2008). The lessons from this evaluation will have relevance to other developing country settings which have promoted the up-scaling of HCT and ART, without simultaneously developing, and actively managing, the implementation of integrated models of pre-ART care at district level. While we have demonstrated the role that pre-ART care plays in the continuum of HIV services, we have not attempted to cost it. In our setting, it has been assumed, perhaps erroneously, that pre-ART can be absorbed by the existing public primary care services. The scale-up of ART services has been accompanied by research on its affordability (Cleary & McIntyre 2010), and additional resources have been made available. Similar costing studies need to be undertaken to inform the choice of model of delivering pre-ART care in resource-limited settings and to motivate for additional resources.
The use of record reviews in this evaluation is a limitation as information recorded in a clinical folder does not necessarily reflect the completeness or quality of the service rendered. In busy settings, note-taking is often poor, and staff do not record all interventions. Customised HIV stationery was developed to prompt a quality consultation and aid note-taking. However, including checklists makes over-recording a possibility as staff may just tick all the necessary boxes. Even if the activity is done (for example, disclosure discussed), there is no guarantee that the topic is covered sufficiently to have impact.
This evaluation also has a number of statistical limitations. The quota method of sampling employed means that the sampling was not proportional to size of the service load or local HIV burdens: 10 patient folders were sampled from each facility. There are precedents for this in other quality improvement processes (Moys 2002) where the emphasis is on identifying major service gaps in an assessment–analysis–action–review process. At facility level, the number of folders reviewed is too small to give statistically precise results. At district level, the aggregated number of folders reviewed becomes considerable (n = 1115) but cannot be taken to be representative of all clients in HIV care in the district as non-probability sampling has limited external validity. We weighted the results of each facility using the case load of positive HCT patients in each facility as a means of reducing the bias as large facilities are relatively under-represented and small facilities are relatively overrepresented. Large facilities if not adequately staffed may provide worse quality of care.
This evaluation shows that while a package of pre-ART care is clearly defined in Cape Town, it has not been fully implemented. Additional resources have not been allocated, and there has been little guidance on service delivery models and on how to operationalise continuity between HCT, pre-ART and ART. We have identified weaknesses in the continuity and quality of service delivered and contend that the implementation of pre-ART care is crucial to create a continuum of care for HIV-positive clients from HCT through to ART. Only then will the key programme objectives of provision of positive prevention and timeous access to ART be possible.
We acknowledge the role of the Cape Town HIV/TB/STI task team, who designed the evaluation tools and provided oversight to the audit process. We commend the vision and commitment of the Health Department (Provincial Government of the Western Cape) and the City Health Directorate (City of Cape Town) in conducting the annual audit; in particular, we acknowledge the energy and professionalism of the subdistrict TB HIV coordinators and staff who collected data and analysed them at facility and subdistrict level as part of an internal quality improvement process. We thank Hilton Snyder for his meticulous work in cleaning and formatting data and Prof Richard Madsen for running the analysis in STATA. Vera Scott was funded by the Rockefeller Foundation and National Department of Health.