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“Melinda and I often get asked how to make a difference in the world. A great way is to volunteer.”
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No 'One Size Fits All'
Putting HIV Patients at the Center
The lessons I drew from my visit to a clinic in South Africa.
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Experts have long recognized that there is no “one-size-fits-all” approach to HIV services. The features of the global HIV epidemic vary by country, often by community and patient, and it’s important to understand these distinctions so that we can design programs to meet people’s needs and strengthen their access to treatment and prevention.

A few months ago, I had the opportunity to meet Craig Househam, who heads the Department of Health in the Western Cape, one of South Africa’s nine provinces. We talked about how his department is delivering health care to the thousands of people living with HIV in the townships and rural areas surrounding the city of Cape Town. I was really impressed with the approach that Professor Househam and his team have created in the Western Cape, and I want to share some of the lessons that I think can be drawn from it.

One thing that the system does well is to tailor the support provided to each HIV patient by offering different tiers of engagement with the health system.

In many countries, all HIV patients are expected to have the same level of engagement with the health system, regardless of their needs. That generally means monthly medical appointments with a doctor or high-level nurse at a central hospital. For many people living far from facilities, these trips often take an entire day due to lengthy travel and significant wait times. For the majority of patients who are generally healthy and responding well to their medications, this level of engagement with the healthcare system may be burdensome and  actually discourage patients from remaining in care. For others with more complicated cases, this standardized level of care may be insufficient.

In the system in the Western Cape, healthy patients who are adhering to their anti-retroviral (ARV) treatment can pick up their medicine every two months from local service organizations rather than from a central hospital or clinic. Qualified pharmacists sort and package the medications, and then they are delivered to patients by mid-level healthcare workers rather than doctors or nurses. This lets people access quality services in their own neighborhood, reducing the burden on them and on the health system overall. To ensure that people are staying healthy and not developing resistance to their treatment, the Western Cape schedules everyone for an annual clinical exam with a highly qualified nurse. If there are problems, patients are immediately referred to a doctor for further examination. 

I was also impressed by how the Western Cape collects the data required to understand which level of engagement is appropriate for the individual patient. They are phasing out their paper-based records and adopting an electronic health record that creates individual e-files for patients and links their lab results, hospital records, and other information under one file that can be accessed wherever an individual seeks care.

Why am I so excited about this approach?

First, this system takes into account the specific needs of the individual receiving care. By providing patients only the level of care they need, it leaves them more time to devote to their jobs, their families, and their communities. 

Second, it enhances the impact of scarce healthcare resources—financial, human, and technical. By reducing the cost and effort while still keeping thousands of people healthy, it frees up resources that can be directed toward more specialized care for those who need it—or toward expanding access to treatment for those who don’t have it.

Third, the Western Cape’s approach uses smart IT solutions to meet patients’ clinical needs and providers’ logistical needs. It is preparing the way for an even more efficient, patient-focused health records system that can facilitate a better managed HIV treatment system at a lower cost to the public. This is especially important in countries like South Africa, where many patients might be on the move; electronic records can follow a patient much more easily than paper ledgers.

Approaches like these remain critical in our efforts to turn the tide on HIV. We have made huge progress against HIV in the past decade, thanks in no small part to programs like PEPFAR and the Global Fund for AIDS, Tuberculosis, and Malaria. The cost of ARV medicines has fallen by more than 99 percent, and more than eight million people now have access to lifesaving treatment. But we still face a situation where only half of all people who could benefit from HIV treatment are actually receiving it. And that means we have a moral obligation to be smarter about how we organize treatment programs so that people in treatment are able to live longer and so that fewer people die for lack of access to treatment.

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