ITEM VIEW

An evaluation of the effectiveness of task-shifting health systems approaches, including community-based and pharmaceutical care models, for HIV treatment and prevention programs in South Africa

dc.contributor.advisorChikte, Usuf M. E.en_ZA
dc.contributor.advisorNachega, Jeanen_ZA
dc.contributor.authorFatti, Geoffrey
dc.contributor.otherStellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Global Health. Epidemiology and Biostatistics.en_ZA
dc.date.accessioned2020-10-19T09:49:00Z
dc.date.accessioned2021-01-31T19:36:06Z
dc.date.available2020-10-19T09:49:00Z
dc.date.available2021-01-31T19:36:06Z
dc.date.issued2020-12
dc.identifier.urihttp://hdl.handle.net/10019.1/109118
dc.descriptionThesis (PhD)--Stellenbosch University, 2020.en_ZA
dc.description.abstractENGLISH SUMMARY : Southern Africa is the epicenter of the human immunodeficiency virus (HIV) pandemic having the highest burden of HIV globally. Although South Africa has made great strides with the roll-out of its antiretroviral treatment (ART) program, ongoing challenges include high attrition of patients from ART care and ongoing elevated HIV incidence. There is also a severe shortage of professional health workers in the region, which impacts HIV program delivery. Task-shifting health systems approaches have been developed in order for the health system to provide large-scale HIV program delivery with limited numbers of professional health workers. This thesis evaluates the effectiveness of task-shifting health systems interventions in HIV prevention and treatment programs in South Africa, including community-based programs utilizing community healthcare workers (CHWs), and pharmaceutical care models. Data were collected in cohort studies conducted between 2004 and 2015/2016 in four provinces of South Africa. The results chapters of the thesis are presented in the form of published papers. The first paper evaluates the effectiveness of a community-based support (CBS) program amongst a large cohort of adults living with HIV receiving ART up to five years after ART initiation. Adults who received CBS had improved ART outcomes, including improved patient retention with lower loss to follow-up and lower mortality, both of which were reduced by one third. The second paper evaluates the effectiveness of a community-based combination HIV prevention intervention delivered by CHWs for pregnant and postpartum women in a high HIV incidence district in KwaZulu-Natal. Maternal HIV incidence amongst participants who received the intervention was considerably lower compared to other studies from the region. The paper further recommends expanded roll-out of home-based couples HIV counselling and testing, and initiating oral pre-exposure prophylaxis for HIV particularly for pregnant women within serodiscordant couples, in order to reduce maternal HIV incidence. The third paper compares the effectiveness and cost of two task-shifting pharmaceutical care models for ART delivery in South Africa, namely the indirectly supervised pharmacist assistant (ISPA) model and the nurse-managed model. The ISPA model was found to have a higher quality of pharmaceutical care, was less costly to implement and was possibly associated with improved patient clinical outcomes. The fourth paper evaluates the effectiveness and cost-effectiveness of CBS for adolescents and youth receiving ART at 47 health facilities in South Africa. CBS was found to substantially reduce patient attrition from ART care in adolescents and youth, and was a low cost intervention with reasonable cost-effectiveness. Lastly, a published scientific letter is included as an appendix, which is a critique of findings from a cluster-randomized trial investigating the effectiveness of two interventions as part of the current South African National Adherence guidelines (AGL). The letter recommends the inclusion of long-term CBS for ART patients utilizing CHWs in a revised version of the AGL. The thesis concludes that task-shifting healthcare models including communitybased and pharmaceutical care models are effective and cost-efficient for HIV program delivery in South Africa, and can aid the greater Southern African regions’ progress toward several of the interrelated UNAIDS Sustainable Development Goals by 2030.en_ZA
dc.description.abstractAFRIKAANSE OPSOMMING : Suider-Afrika is die episentrum van die menslike immuniteitsgebreksvirus (MIV) pandemie, en het wêreldwyd die grootste las van MIV. Alhoewel Suid-Afrika groot vordering gemaak het met die instelling van sy antiretrovirale behandelingsprogram (ARB), is daar voortdurende uitdagings insluitende 'n hoë verlies van pasiënte vanuit ARB-sorg en 'n verhoogde insidensie van MIV. Daar is ook 'n ernstige tekort aan professionele gesondheidswerkers in die streek, wat die lewering van MIVprogramme beïnvloed. Taakverskuiwende benaderings vir gesondheidstelsels is ontwikkel sodat die gesondheid sisteem MIV-programme op groot skaal kan verskaf met beperkte aantal professionele gesondheidswerkers kan aanbied. Hierdie tesis evalueer die doeltreffendheid van intervensies van gesondheidstelsels in MIVvoorkomings- en behandelings programme in Suid-Afrika, insluitend gemeenskapsgebaseerde programme wat gebruik maak van gemeenskap gesondheidswerkers (CHW's) en farmaseutiese sorg modelle. Data is versamel in kohort studies tussen 2004 en 2015/2016 in vier provinsies van Suid-Afrika. Die resultate van die tesis word aangebied in die vorm van gepubliseerde artikels. Die eerste artikel evalueer die doeltreffendheid van 'n gemeenskap-gebaseerde steun program (CBS) onder 'n groot groep volwassenes wat met MIV leef, wat ARB tot vyf jaar na ARB inisiëring ontvang. Volwassenes wat CBS ontvang het, het verbeterde ARB-uitkomste insluitend verbeterde pasiëntretensie, en verminderde verlies aan opvolg en verminderde mortaliteit; albei is met een derde verminder. Die tweede artikel evalueer die doeltreffendheid van 'n gemeenskap-gebaseerde kombinasie MIV-voorkomings program wat deur CHW's gelewer word vir swanger en postpartum vroue in 'n distrik met 'n hoë MIV-voorkoms in KwaZulu-Natal. MIV-voorkoms van moeders wat die intervensie ontvang het was aansienlik laer in vergelyking met ander studies uit die streek. Die artikel beveel verder aan dat huisgebaseerde paartjies MIV-berading en -toetsing uitgebrei moet word, en om mondelinge voorkomings-behandeling vir MIV in te stel, veral vir swanger vroue binne serodiscordant paartjies, om MIV-voorkoms in moeders te verminder. Die derde artikel vergelyk die effektiwiteit en koste van twee taakverskuiwende farmaseutiese sorg modelle vir ARB-voorsorg in Suid-Afrika, naamlik die indirekte toesighoudende aptekerassistent (ISPA) -model en die verpleegsterbestuurde MIV inledings model. Die ISPA-model het 'n hoër gehalte farmaseutiese sorg gehad, was goedkoper om te implementeer en was moontlik geassosieer met verbeterde kliniese uitkomste van pasiënte. Die vierde artikel evalueer die doeltreffendheid en kosteeffektiwiteit van CBS vir adolessente en jeugdiges wat ARB by 47 gesondheidsfasiliteite in Suid-Afrika ontvang. Daar is gevind dat CBS die verlies van ARB-sorg onder adolessente en jeugdiges aansienlik verminder, en dat CBS 'n lae koste-intervensie was met redelike kostedoeltreffendheid. Laastens word 'n gepubliseerde wetenskaplike brief as 'n bylaag ingesluit, wat 'n kritiek is op bevindings van 'n groep-gerandomiseerde proef wat die doeltreffendheid van twee intervensies ondersoek as deel van die huidige Suid-Afrikaanse riglyne vir nasionale nakoming (AGL). Die brief beveel aan dat langtermyn CBS met die gebruik van CHWs vir ARB-pasiënte in 'n hersiende weergawe van die AGL ingesluit moet word. Die tesis kom tot die gevolgtrekking dat taakverskuiwende gesondheidsorg modelle, insluitend gemeenskapsgebaseerde en farmaseutiese sorg modelle effektief en kostedoeltreffend is vir die verskaffing van MIV-programme in Suid-Afrika, en ook kan bydra tot vordering van die groter Suider-Afrikaanse gebied na die interafhanklike UNAIDS volhoubare ontwikkelingsdoelwitte vir 2030.af_ZA
dc.format.extentxii, 167 pages ; illustrations, includes annexures
dc.language.isoen_ZAen_ZA
dc.publisherStellenbosch : Stellenbosch University
dc.subjectHIV (Viruses) -- Epidemiology -- South Africaen_ZA
dc.subjectCommunicable diseases -- Prevention -- South Africaen_ZA
dc.subjectCommunity health aidesen_ZA
dc.subjectTask-shifting -- Evaluationen_ZA
dc.subjectHealth care teamsen_ZA
dc.subjectUCTD
dc.titleAn evaluation of the effectiveness of task-shifting health systems approaches, including community-based and pharmaceutical care models, for HIV treatment and prevention programs in South Africaen_ZA
dc.typeThesisen_ZA
dc.description.versionDoctoral
dc.rights.holderStellenbosch University


Files in this item

Thumbnail
Thumbnail

This item appears in the following Collection(s)

ITEM VIEW