Did you know that the best way to reduce new HIV infections is to ensure that patients remain on treatment and become virally suppressed?
An innovative case management approach, introduced by Health Systems Trust in uMgungundlovu District, is helping patients to stay in the system, adhere to their treatment, and become virally suppressed.
uMgungundlovu District in KwaZulu-Natal currently has the highest HIV prevalence in the world.
Case management focuses holistically on each individual and recognises the variety of factors that affect patients' ability to adhere to treatment, from transport and nutrition to depression and family problems. Case Managers develop a comprehensive plan for each client that focuses on both psychological and clinical care.
Phetha chatting with her case manager Nokwanda Mbele
Ntombenhle Phetha (33) was about to stop taking antiretroviral medication when an HST Case Manager contacted her and changed her mind.
"The Case Manager came to my house just after I'd decided I wasn't going to go back to the clinic, because I was very unhappy with the care I was getting there. It was always difficult for them to find my file and the nurses spoke badly to me. I'm also being treated for depression and they would call me for an appointment on one day for my psych meds and on another day for my ART. Sometimes I would queue for hours only to find they didn't have stocks of the medicine I needed."
Unemployment and poverty also leads to patients quitting ART because they don't have enough food at home. "It is difficult for people to take their treatment without eating a meal first. How can you take meds on an empty stomach?" says Phetha.
Phetha is a lesbian, which has created many family problems. "These problems led me to think about suicide quite often, which is why I got depressed and had to take these psych meds."
Nokwanda Mbele was assigned to Phetha's case and has been instrumental in keeping her on treatment. "Nokwanda had noticed that I'd been missing my clinic appointments. I told her I wanted to stop treatment or move to another clinic. Nokwanda promised she would take care of my case so that I don't have to queue for such a long time. She also arranged for me to collect both my treatments at one appointment. I feel like I have a champion, someone who is on my side when I come to the clinic."
Phetha says that she feels much stronger now Nokwanda is acting as an advocate for her as a patient. Nokwanda helps her to remember to take her medications and to attend her clinic appointments. "If I have problems, I can call and explain to her. This makes me feel I am not alone."
Once Phetha has completed 12 months on treatment, and is clinically stable and virally suppressed, she will graduate to the CCMDD programme, which allows her to collect her medication from a convenient pick-up point such as a retail pharmacy without having to queue at the clinic.
Siboniso Cele (39) is a security guard and the father of one child. He works 12-hour shifts in a post far out of town, which makes it difficult to get to the clinic during opening hours.
"This system is much better because now I queue for a maximum of 30 minutes. Before we would wait a very long time, even the whole day.
The Case Manager helps me to keep my appointments by phoning to remind me. After one year, if I am stable on my treatment, I'll be able to join CCMDD and my medication can be collected by someone else from a place like Clicks, or on my way through town to work, I can just stop and collect my medicine."
Cebisa Ngcobo (39) says that the new system not only helps her to maintain her treatment, it also keeps her safe from crime.
"Before this new system, I would have to queue at the clinic very early in the morning while it's still dark. If you came later, you would end up waiting the whole day. When we walked in the dark we would get robbed by the tsotsis who would take our phones and even steal our antiretroviral medicine.
But now my Case Manager helps me to set a convenient time for my appointments and I don't even wait more than 10 minutes. I'm so happy with this system that I encourage others who have been put off by bad experiences in the past to return to the clinic; I tell so many people about it that they say it's like I'm advertising. That's good. People must know that things are getting better now."
Jabulani Mkhize (24) is a chef and has been on ART for almost a year. He says that the introduction of the case anagement system has definitely helped him to adhere to his treatment. "My Case Manager will call to make sure that I can attend my appointment."
"If you know your status, you don't need to be ashamed. Life goes on."
He says that the stigma around HIV is decreasing in his community: "People are more educated about HIV now, to the point that we can even joke about it with our friends. There are also other people in our family on treatment. I am gay and I think there is much more stigma about my sexual orientation than my HIV status. Some of the counsellors and nurses at clinics should be educated on how to engage with us and how to ask questions sensitively."
"Case management entails closer and more regular communication with patients – proactively managing their condition before they withdraw or disappear from clinic engagement," says Nomvula Radebe, HST's District Co-ordinator for uMgungundlovu. "This begins the minute after diagnosis, so that there is no delay in linkage to care. The key actions are clustering, documenting and reminding – all the while carrying the patient through a supportive care plan."
To access the first edition of HST's Phakama Digest – which features an in-depth perspective on the technical aspects of implementing the HIV Case Management Model – go to: https://www.hst.org.za/publications/HST%20Publications/PHAKAMA%20DIGEST%20July%202019.pdf
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