Page 176 - SAHCS HIVMed Journal Vol 20 No 1 2019

Page 7 of 8 Original Research

Limitations Conclusion

Assessment of long-term effectiveness of interventions In this study, multifaceted interventions focusing on
implemented during this operational research is difficult to laboratory systems, staff training and mentoring, streamlined
measure accurately for the following reasons: difficulty of documentation and a strong referral and follow-up system
measurable end points; the presence of the research clinicians contributed to improvements in virologic management in the
pre- and post-intervention, with availability for assistance time period evaluated.
and advice, and a split focus between intervention and
review; and the progressive nature of the research, with the The third ‘90’ UNAIDS 2020 target is therefore achievable by
need to design tools for measurement while interventions are the implementation of simple, appropriate and targeted
occurring.
systems in a busy PHC setting.
The multifaceted interventions in this study included support
from two part-time research clinicians with HIV experience Recommendations
and research assistants who were actively involved in patient While it may not be feasible to place extra clinicians at
care. Hence, while the interventions were fairly simple, it clinics for the sole purpose of mentoring and documentation
may not be feasible to institute this level of health systems review, several of the interventions are easy to implement
strengthening at all clinics. Moreover, it is difficult to assess in a resource-poor setting. This includes the clinical
which intervention had the most effect given the package of summary chart as a simple way to monitor VL status.
care. Finally, while there was some emphasis on empowering
patients in their HIV care, the effect of this on knowledge and Moreover, routine education of clinical staff on basic
behaviour was not measured. South African governmental protocols is achievable. Finally,
with the introduction of Tier.net, an electronic database for
Follow-up of patients not returning to the clinic was difficult HIV-positive patients and access to the NHLS laboratory
to assess because there was no appointment system in place, results system, improvements to the result availability are
and missed visits were not easily identified until a patient feasible.
returned to the clinic and the file was taken out, or, as in this
study, all the files reviewed. Despite this, retention in care Acknowledgements
was 88% and 79% in the in-depth review and the VL
retention in care review, respectively, possibly indicative of The authors thank Vicky Zuma, Pamela Ndamase, Thembi
the commitment of patients to the care they were receiving Ngubane, Thabsile Maluleka, Azile Soqashe, Mandisa
at the Lancers’ Road PHC. In a prior retrospective study of Nokwali and Sizipiwe Dayi, and also thank the clinical and
South African ART cohort, overall retention rates fell from administrative staff at the Lancers Road PHC whose co-
71% at 24 months to 56% at 60 months; notably these study operation is gratefully acknowledged.
25
sites were well resourced. Currently, programmatic data
are limited regarding retention in care in adults in South Competing interests
Africa; studies evaluating postpartum retention in care in
PMTCT also noted challenges in attrition because of patient- The authors declare that they have no financial or personal
level factors (disclosure to spouse and competing priorities), relationships that may have inappropriately influenced them
provider-level factors (clinical knowledge and attitudes) in writing this article.
and wider health systems barriers, such as access to care
26
and drug stock-outs. The attrition rate following access to Authors’ contributions
universal ART is unclear and there may be a larger loss to
follow-up following the 2016 guideline revision to initiate C.M.C. and J.H. undertook all file reviews, designed the
all patients on ART, irrespective of CD4 count. 27 data entry documents and captured the data; T.N., N.L. and
+
H.N. provided access to patient files; L.M.G.Z. and E.S.
The gaps in patient care at the PHC clinic may be accounted contributed to the clinical oversight; S.R. provided oversight
for by the high patient volume, and prioritisation of ART of laboratory results; T.R. provided statistical support;
initiation and dispensing without the assistance of a G.R. provided funding; A.C. and P.K. conceptualised and
pharmacist. Moreover, there were few opportunities for wrote up the proposal and provided oversight of the
clinicians to mentor nurses. Clinical mentoring has been operational research project. C.M.C. and J.H. wrote the first
highlighted by WHO to be a vital strategy for the scale of draft of the article; T.C., A.C. and P.K. contributed to writing
ART and improving healthcare in developing countries. 28 the final article.

As this study was conducted at a municipality PHC, it may Funding
not be generalisable to other PHC facilities in South Africa.
However, it may be feasible to implement most of the lessons This study was supported by the Metropolitan and
learned in improving the quality of virologic management in Momentum Investment (MMI) Foundation (corporate social
this study. investment arm of MMI Holdings).

http://www.sajhivmed.org.za 169 Open Access