South Africa has the largest HIV treatment programme in the world, with nearly six million people receiving antiretroviral therapy (ART). However, this important achievement is overshadowed by the high number of people who are lost to care. 

Speaking during a session at the International AIDS conference in Germany last week,  director of HIV treatment, care and support in the national health department Dr Musa Manganye says many people interrupt their treatment in the first 12 months of being diagnosed with HIV.

Manganye says the department’s assessment shows that the highest rates of treatment interruption were among adolescent boys and young men aged between 12 and 24. He warns that ART interruption can lead to a decline in CD4 cell count, an indicator of immune function in patients living with HIV. 

“This increases the disease progression leading to advanced HIV disease and other related opportunistic infections. Treatment interruption risks the viral rebound, meaning the virus is now detectable and will likely be transmittable to the client’s sexual partner,” he says. 

This is a major hurdle towards the country meeting the United Nations’ goals of ending the HIV epidemic by 2020. 

”We have to ramp up our efforts to try and bring back the clients who have disengaged to the mainstream,” says Manganye. 

Factors driving treatment interruption 

Mandisa Dukashe, a technical lead on treatment literacy at the South African National AIDS Council says treatment interruption is a big challenge and it has been for a long time. 

The reasons for treatment interruption differ from person-to-person. Recent research by the Anova Health Institute found that relocation or people being on the move – especially for work – were the most common reason.  

“Generally, men don’t seek health services. And when one has to choose between spending time in a clinic queue or queuing for part-time employment, they’ll choose the latter. Some are seasonal workers, a truck will come to fetch workers to work in another province and they won’t think twice and won’t even have time to go to their clinic to ask for a transfer letter to take to the clinic where they will be staying,” Dukashe tells Health-e News. 

Professor Khangelani Zuma, from the Human Sciences Research Council (HSRC) says it is worrying that only 63% of young people aged 15 to 24 living with HIV are on ART. According to the latest HIV prevalence survey released by the HSRC this week, more than half a million people in this age group have HIV. 

“Several factors are at play that make the youth apprehensive and disengaged. There is a need to relook at the structure of our counselling in the health sector. That is, who do we use to speak to young people and how do we speak to them,” He says. “Most interventions fail among the youth because elderly people want to  impose their thinking on young people. This disconnect will arguably lead to disengagement.”

What needs to happen

Dukashe says the government should establish and fund peer-led programmes. These should include safe spaces where young people diagnosed with HIV can get non-judgmental support. 

“Mental health and psychosocial support should be considered for all affected populations. Government should scale up community based ART initiation sites to ensure clients don’t spend days in long queues. It should also ⁠fast track the multi-month dispensing of medication. There is a need to establish external pick up points in rural areas where people won’t have to spend money travelling to towns to collect treatment,” she says. 

Zuma adds that a drive aimed at engaging communities and participation of various stakeholders is key. 

“It cannot be the responsibility of the government alone to confront the epidemic. Interventions that exclude communities are bound to fail. It is the partnership between government and communities that will make the cut,” he says. 

What government is doing 

Manganye says the department has realised that they need to focus on clinical assessment of those who default on their treatment and service delivery issues. 

“The guidance from the World Health Organisation has been central in guiding what we focus on and what we should do differently as we welcome our clients back to the mainstream. Part of it is to make sure that we are kind and not judgemental, because the very first experience matters most,” he says. 

“There are two factors that we have to  consider as we re-engage with our clients. The clinical assessment of the people who are returning  as well as the duration of time the client had interrupted their treatment. 

“When it comes to the clinical factors, we look at the CD4 count to determine whether we could offer the same treatment they were on or if there is a need to do a switch of treatment. The treatment we give them will depend on whether the client who interrupted treatment returns before 28 days of interruption or after 28 days,” he says. 

Manganye explains that people who’ve not taken ART for longer than 28 days risk developing drug resistance. 

“Drug resistance is largely man-made and is a consequence of suboptimal regimens and treatment interruptions. That’s why the current guidelines encourage the application of a differentiated approach upon the return of the clients by considering clinical factors and the period within which the client interrupted treatment,” he says. 

“So we need to make sure flexibility is applied both for people who are interrupted treatment for 28 days and those who came after the stipulated time.” – Health-e News