The programme has increased rapidly since inception from 1800 people on ART by 31 October 2006 (after 2 years of ART programme) to 7576 by 31 December 2008. Further, from January 2008, CD4 results of those accessing testing in the clinics have also been documented (). At the time of data censoring (31 December 2008) the database contained results for 19 566 individuals, 14 280 (73.0%) of whom were female. The over-representation of females is a reflection of the local prevalence10
and continues to be illustrated in those initiated onto treatment (). In 2004, in the ACDIS, overall, 27% of female and 13.5% of male residents were HIV infected.10
Aspects of equity and access to treatment are currently being examined, but preliminary findings suggest that males are only slightly less likely to access treatment in comparison to females (Personal Communication F Tanser, Africa Centre, 2009), contrary to recent reports that more attention needs to be paid to ensure men access HIV treatment and care.21,22
Cumulative total of persons who have accessed the Hlabisa HIV Treatment and Care Programme, showing those initiated onto ART, those with CD4 tests but not yet initiated and those lost to follow-up or deceased
Distribution by age and sex of those initiated on ART in the HIV Treatment and Care Programme
There were 8832 adults with CD4 counts >200 cells/µl, thus not yet eligible for treatment, and 2689 adults with eligible CD4 counts but not yet started on ART within our programme where there is no waiting list for treatment (). There are multiple possible reasons why this latter group has not started ART; they may have moved out of the district, not returned to access their CD4 results, were in the process of being initiated, have started ART in the private sector or local NGO programmes or have died. Of the patients initiated, the median CD4 at initiation was 118 cells/µl and plasma viral load 4.58 Log; most people started on the efavirenz containing regimen (). Among children, the median age at initiation was relatively high, with half initiating treatment at ≥6 years of age. The majority of children were already in WHO stage 3 or 4 at the time of initiation. However, early results suggest success can be achieved with clinical, immunological and virological improvement in this rural paediatric cohort.23
Characteristics of individuals enrolled in the Hlabisa HIV Treatment and Care Programme
In 2008, an average of 253 adults and 27 children were initiated every month. In the paediatric cohort, 667 children (≤15 years old) had been initiated onto ART by 31 December 2008 (8.8% of the total initiated). Only 48 (7.2%) infants (≤1 year old) were initiated on ART illustrating the enormous challenges of identifying and treating young children. Strategies have recently been implemented to increase the overall number of children on treatment, concentrating on infants, including strengthening the follow-up of mothers and infants in the local PMTCT programme, ensuring PCR testing of infants at 6 weeks of age and fast tracking of infected infants for treatment.
The home-based care (HBC) branch of the programme has increased significantly since October 2007, when service level agreements were formalized between existing local care organizations and the Hlabisa HIV Treatment and Care Programme. By February 2009, 24 HBC organizations had been recruited, with 540 volunteers covering 5800 patients.24
Carers visit community members after referral from multiple sources including community members, hospitals or clinics and local NGOs. Two full-time professional nurses and a dedicated social worker are also employed in the team.
Three interventions have been implemented in the sub-district to increase access and uptake of HIV testing. In the 16 fixed PHC clinics, between 1000 and 1500 people are tested and counselled for HIV each month; and, from early 2009, the programme has offered a Home and Mobile Testing Service employing seven counsellors, counsellor supervisors and one full-time coordinator. It operates in areas outside the DSA, offering rapid HIV testing in one of two modalities; home-based VCT in individual houses or VCT in a mobile unit. Secondly, the use of Provider-initiated Testing and Counselling (PITC) has been piloted in the sub-district.25
The pilot resulted in a 3-fold increase in HIV testing rates in the month after implementation.26
Currently, the model has been expanded to a further five clinics before roll-out to all 16. Finally, TB and HIV services in the sub-district have been integrated so that there is a physical proximity between the two services at each clinic; all TB patients are offered an HIV test and almost 90% accept.27,28