EXECUTIVE SUMMARY

The Khayelitsha programme was the first in South Africa to provide antiretroviral therapy (ART) at primary care in the public sector. It is also one of two pilot projects in the country to provide decentralized care for drug-resistant tuberculosis (DR-TB). This report highlights the key clinical, programmatic, and policy changes that have supported universal coverage for HIV and TB care and outlines future challenges and potential models for long term ART care.

ART is feasible in poor settings. The project was started in 1999 (first patients initiated on ART in 2001) to demonstrate feasibility of providing ART at primary care in a resource limited setting. Initial success contributed to the paradigm shift from the consensus that ART was not feasible in poor countries to making it a priority. In 2004, the project was incorporated into the provincial ART programme, and the objective shifted towards coverage of ART needs.

Antenatal HIV prevalence has stabilized. HIV antenatal prevalence increased from 15% in 1999 to 32% in 2006 and has remained stable since. The absence of further increase in prevalence despite the large expansion of ART and the reduction in HIV-associated mortality might result from a decrease in new infections. In the absence of reliable incidence measures, the effectiveness of prevention activities remains difficult to assess.

Large scale condom distribution, ‘€žopt out’€Ÿ integrated HIV testing and counselling, and men-oriented services. The massive scale up of condom distribution in 2006 has been associated with a 50% drop in the incidence of sexually transmitted infections (STIs). The introduction of large scale voluntary counselling and testing by lay counsellors, the availability of prevention of mother to child transmission, and later the shift to ‘€—opt-out’€˜ HIV testing and counselling for TB suspects, STI clients, family planning services, youth etc. resulted in the increase of people tested in Khayelitsha from less than 500 in 1998 to 40,000 in 2008. The opening of a male walk-in clinic in Site C led to a sharp increase in the proportion of men testing and STI consultations within the first year of implementation. To further scale up HTC alternative options should be explored in addition to facility-based HTC.

Integration of ART within midwife obstetric units (MOU) and a very successful prevention of mother to child transmission (PMTCT) programme. Almost 100% of pregnant women are tested for HIV in Khayelitsha. HIV-positive women with a CD4 count below 200 receive ART within the MOU at one pilot site; women not eligible for ART receive AZT from 28 weeks of pregnancy and single dose nevirapine during labour. This strategy has achieved to reduce HIV MTCT to 3.3%. To achieve universal coverage, it will be necessary to integrate midwife-led ART within antenatal consultations everywhere in South Africa.

Decentralization of nurse-led, TB/HIV integrated ART services to every clinic has resulted in more than 13,000 patients being on ART at the end of 2009 and ongoing increases of new enrolments despite the scarcity of staff. Outcomes were good, with 70 % remaining in care and less than 15 % with virological failure at 5 years on ART, a decrease in patients presenting with low CD4 counts, and decreasing mortality on ART. This primary care model was applied to children as well, for whom retention in care was better than adults at 87 % at 5 years on ART.

The greatest challenge for the scale-up now is how to retain patients in care over the long-term, while at the same time increasing enrolment on ART. As the number of people started on ART in Khayelitsha increased, so did the proportion of patients lost to follow-up. Adherence clubs were started in Khayelitsha to maximize clinic efficiency and improve support for stable patients on chronic ART. Early results of this pilot project are promising and it is expected that adherence clubs will play a major role in achieving the NSP targets of coverage. Youth proved to be at especially high risk of defaulting ART. Treatment literacy provided by the Treatment Action Campaign (TAC) in facilities and the community is an essential part of the programme.

Full report attached.