The impact of a large scale treatment program on HIV treatment delivery in a resource limited setting: a case study of urban treatment in Johannesburg, South Africa
Date
2016
Authors
Long, Lawrence Camdon
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Abstract
Introduction
This thesis investigates the impact of a large-scale HIV treatment program on the
outcomes and costs associated with HIV treatment delivery, using urban South
Africa as a case study. In order to investigate HIV treatment delivery it is broken
down into two major components; 1) the chronic outpatient treatment of HIV and 2)
the acute inpatient treatment of HIV related conditions.
Outpatient HIV treatment
Through task shifting the South African outpatient HIV treatment program evolved
over time to scale up in an environment of limited resources. There is no economic
evaluation of task shifting in a routine environment in South Africa. Papers 1 and
2 focus on understanding the outcomes, costs, and cost effectiveness of partial
and full task shifting. The results of this work provided evidence to support the
shift to nurse initiation and management of antiretroviral treatment (NIMART). It
also highlighted the fact that within the NIMART program there may be a need to
triage patients between primary health clinics and hospital based outpatient clinics
to better utilize scarce resources.
Inpatient HIV treatment
Prior to antiretroviral treatment (ART) inpatient care of acute HIV related
conditions was common, but with the rollout of antiretrovirals in 2004 it was
anticipated that this would reduce. Since 2004 there has been no economic
evaluation, which speaks specifically to the shifting HIV burden on inpatient
facilities. Papers 3 and 4 focus on understanding the HIV burden on inpatient
facilities by examining the outcomes (mortality) and costs associated with HIV
positive admissions. The results show that almost half (45%) of inpatient medical
admissions were confirmed HIV positive, not on ART and accounted for the
majority of the costs. In addition to that, the majority of medical inpatients (58%)
who died were HIV positive, which lends support to other evidence that suggests
that national HIV mortality is seriously under reported in South Africa.
Conclusion
Large-scale ART continues to move outpatient HIV treatment further along the
task-shifting continuum, while maintaining outcomes with some potential
reductions in cost. However, large-scale ART has not had the expected impact of
substantially reducing the HIV burden on inpatient facilities.
Description
A thesis submitted to the Faculty of Health Sciences, University of Witwatersrand, in fulfillment of the requirements for the degree of Doctor of Philosophy
Johannesburg, 2016