By: Judith King (Copy and Content Editor: SA SURE)
Outreach activities for HIV Testing Services (HTS) are designed to reach people who cannot visit a clinic. In communities, there are patients on treatment who require a similar outreach approach.
Patients who are stable on their antiretroviral medication can register on the Central Chronic Medicine Dispensing and Distribution (CCMDD) programme to collect their medicine parcels from conveniently located external pick-up points and adherence clubs, at times that suit them.
However, patients who are not yet stable on their medication, and those who do not meet the criteria for differentiated care, cannot benefit from this option − yet they come from the same disadvantaged circumstances as those who do qualify for CCMDD registration.
"While extended clinic hours and case management have served some of these patients well," says Nomvula Radebe (the SA SURE Project's District Co-ordinator for uMgungundlovu District in KwaZulu-Natal Province), "there are many other patients who struggle with visiting a clinic because of unchanging barriers − even with a properly negotiated adherence plan having been agreed to at the start of their treatment."
Nomvula Radebe, SA SURE uMgungundlovu District Co-ordinator.
In January 2020 − before the COVID-19 pandemic took hold in South Africa − the SA SURE team in uMgungungdlovu launched an innovative solution to improve clinical service delivery for such patients. This intervention strategy entails establishing facility-serviced, Nurse-led outreach pick-up points, as well as home medicine delivery once a month.
A standard operating procedure for the intervention was developed and endorsed by the Department of Health, and the roll-out has been expanded to serve both Spaced Fast Lane CCMDD and non-CCMDD patients at designated community sites that are convenient for them to access, or at workplaces and households.
As the year progressed and we entered 2021, the lockdown restrictions on physical movement and proximity have heightened the need for community-based HIV and other health services, especially in the district's hard-to-reach areas. Clinician-led pick-up points support COVID-19 prevention and control measures by reducing the numbers of people travelling to clinics and decongesting the facilities.
The Nurse Clinicians work with the team's Case Managers and Linkage Officer to ensure that patients – especially those who have missed their scheduled appointments – are returned to care and can make appointments for clinical services in the community.
The Clinicians take the CCMDD patients' medicines that are kept at the facility and deliver them to the outreach pick-up points. Facility-based patients are clustered geographically, registered in an appointment system, and traced via telephone call or SMS. These patients then meet the Nurse at a centralised point in the community, where the patient's medication is issued and other service elements such as HIV Testing Services including index case contact testing, initiation on antiretroviral therapy (ART), viral load monitoring, and script renewal, are provided.
The Nurse Clinician confirms the next appointment date for the patient and documents this on the patient's appointment card and file. The patient's file is updated with details of all services rendered during the visit by the facility's Data Capturer, and this information is recorded in the Health Patient Registration System (HPRS) and TIER.Net – a data management system that is used to capture patients' HIV and TB information at facility level, and which is also integrated with the District Health Information System (DHIS) for reporting various programme data from sub-district to national levels.
“We recommend using of a special register containing notes on the Clinician−patient interaction during the visit,” explains Radebe. “This provides a valuable resource for facility staff to review when seeking to understand the reasons for missed appointments and where new pick-up points can be strategically located – which then guides the identification of stakeholders with whom to engage for establishment of sites.”
A patient is attended to by Linkage Officer
Nhlanhla Dlamini and Campaign Agents Thabisile Dlamini and Gloria Makhonza.
By the end of May 2020, four of the project's 15 Siyenza facilities were implementing this modality for continuation of care, and Impilwenhle Clinic in Edendale (which was the first facility to offer this option), had 12 pick-up points serving an average of 28 patients per site. East Boom Community Health Centre in Pietermaritzburg (a non-Siyenza site) had 207 active patients registered for Nurse-led pick-up points. Siyenza facilities are named after the SA SURE Project’s plan of action called Siyenza (‘We do’).
SA SURE Facility Team Leader Sr Phungula leads the Impilwenhle team that provides services to workers at Steddy Farm, who − along with the farm-owner − have expressed their delight with receiving these services at their workplace.
Productivity is no longer affected by workers having to take a day's leave to attend the clinic, meaning minimal financial loss for the farm, and because they need not spend money on travelling to a clinic, none for the workers.
"We are proud to have seen great improvements since we started this service," says Sr Phungula. "Our patients are stable on treatment; some are virally suppressed and have been registered on CCMDD."
Sr Phungula in the mobile pick-up point.
SA SURE Nurse Clinician Sibongile Hadebe shares her experience of setting up a Nurse-led pick-up point while supporting the Khan Road Clinic in Pietermaritzburg:
"We established an outreach pick-up point at uMsilinga Primary School, and one of the patients I attended to there was grateful to be re-initiated on treatment. She knew several people who had been unable to collect new supplies of their medication because they risked being robbed while walking alone to the facility. She said that she would spread the word about our new, convenient service-point, and was true to her word: 12 patients came to the school pick-up point for our services."
Driver Mobiliser Gracious Dlamini tells of Zandile* whom he knew from Sobantu and now resides at France location. Zandile was a patient whose treatment had been interrupted and was re-initiated on ART by the team. She mobilised more patients who had stopped taking their treatment or had shared their medication in the community to attend the Nurse-led pick-up point for return to care. The site has been named after this patient and its user profile continues to grow. (*Not her real name)
Driver Mobiliser Gracious Dlamini.
By June 2020, the number of sites had increased by 138% from 13 to 32, tripling the number of patients provided with community-based clinical services. By October 2020, 17 000 medicine parcels had been issued through this modality.
The goal is to scale up this service option by at least 100% − from 32 to 59 sites in uMgungundlovu – so that more patients can benefit from its clinical and financial advantages.
The success of this intervention has inspired another implementation project that will help to establish community-based ART services as a standard of care: through the DO ART Demonstration Study, comprehensive HIV screening services, treatment initiation and ongoing community-based management of patients on ART will be delivered in eThekwini and Zululand Districts. The SA SURE Plus project offers ARVs and other chronic medication to clients registered for CCMDD in the eThekwini, Umgungudlovu, Uthukela and Zululand districts.
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