The importance of primary care in South Africa’s HIV treatment programme

The development and provision of antiretroviral therapy to treat HIV has been one of the greatest successes in global public health. Antiretrovirals are now being taken by 30 million people with HIV worldwide, giving a life expectancy similar to people without HIV. By suppressing HIV to undetectable levels in the blood, antiretrovirals prevent AIDS-related illness, but also mean that people with HIV can have condomless sexual intercourse with partners who do not have HIV, with zero risk of transmission, as endorsed by UNAIDS through the U = U campaign.

In high-income countries like the United Kingdom, antiretrovirals are often provided through specialist HIV or infectious diseases clinics. However, in low and middle-income countries like South Africa, which has approximately 8 million people living with HIV, a more decentralised, primary care approach has often been used. Since 2004, antiretroviral therapy has gradually been scaled up in South Africa, with around 5 million people now receiving free antiretrovirals through the public sector primary care system. This has been made possible through a public health approach that includes comprehensive training of primary care nurses and the development of clear, streamlined treatment algorithms and guidelines. This means that antiretrovirals are now available from nurses at over 4000 primary care facilities, with support from medical officers and HIV specialists at district hospitals and through free-phone national clinical treatment hotlines.

As the antiretroviral therapy program has matured, it has had to adapt from providing antiretrovirals and associated care to people who were often very unwell, to now being a programme that has to efficiently provide treatment to people with much fewer medical needs. New antiretrovirals have also been introduced which are more potent and have less side effects, which further reduces the need for clinical input. To help provide treatment more efficiently, South Africa now allows people who are doing well on treatment to collect their medication in the community, at private pharmacies, community organisations or through medication ‘ATMs’ or electronic lockers, which are often more convenient and closer to home than clinics. People can then attend the clinic every 6 or 12 months to see a nurse for a quick review and a viral load blood test, to confirm that the treatment remains effective.

The primary care antiretroviral programme has had a measurable impact on the health of South Africans. Life expectancy at birth in the general population has risen from 56 years in 2010, to 65 years in 2019, largely due reductions in HIV-related deaths. However, many challenges still remain. Approximately 2 million people are still not on treatment, despite it being freely available, and some people struggle to remain on treatment consistently, sometimes due to having to relocate for employment or when looking for work. HIV-related stigma remains an issue, which can also stop people from testing for HIV or from starting and remaining on treatment. Better integration of HIV with other primary care services could help to reduce stigma and make HIV care more accessible. A new focus on integration of HIV services with other primary care programs is becoming even more important as people with HIV get older and develop other chronic conditions. For example, there is evidence that people with HIV are at a slightly higher risk of developing cardiovascular disease, and so integration of non-communicable disease management with HIV will be crucial. Lessons from the HIV programme can also be applied to improve the management of diabetes and hypertension in South African primary care, with better use of treatment targets, guidelines and programmatic performance monitoring.

How is the Nuffield Department of Primary Care Health Sciences contributing to improving HIV care?

In the Nuffield Department of Primary Care Health Sciences, we have conducted research alongside the Centre for the AIDS Programme of Research in South Africa (CAPRISA), looking at the impact of community antiretroviral delivery programmes, the rollout of new antiretroviral regimens, and the development of new point-of-care testing strategies to improve HIV treatment monitoring in primary care. We hope that our research can help improve primary care HIV services, and contribute to better healthcare for people with HIV.