To implement and evaluate a formal pre-antiretroviral therapy (ART) care service at a district hospital in Swaziland.
District hospital in Southern Africa.
1171 patients with a previous diagnosis of HIV. A baseline patient group consisted of the first 200 patients using the service. Two follow-up groups were defined: group 1 was all patients recruited from April to June 2009 and group 2 was 200 patients recruited in February 2010.
Introduction of pre-ART care—a package of interventions, including counselling; regular review; clinical staging; timely initiation of ART; social and psychological support; and prevention and management of opportunistic infections, such as tuberculosis.
Primary and secondary outcome measures
Proportion of patients assessed for ART eligibility, proportion of eligible patients who were started on ART and proportion receiving defined evidence-based interventions (including prophylactic co-trimoxazole and tuberculosis screening).
Following the implementation of the pre-ART service, the proportion of patients receiving defined interventions increased; the proportion of patient being assessed for ART eligibility significantly increased (baseline: 59%, group 1: 64%, group 2: 76%; p=0.001); the proportion of ART-eligible patients starting treatment increased (baseline: 53%, group 1: 81%, group: 2, 81%; p<0.001) and the median time between patients being declared eligible for ART and initiation of treatment significantly decreased (baseline: 61 days, group 1: 39 days, group 2: 14 days; p<0.001).
This intervention was part of a shift in the model of care from a fragmented acute care model to a more comprehensive service. The introduction of structured pre-ART was associated with significant improvements in the assessment, management and timeliness of initiation of treatment for patients with HIV.
Impact of pre-ART care on the quality of care in a district hospital in Southern Africa.
After introduction of a pre-ART care service, a higher proportion of patients were assessed for ART, a higher proportion of those eligible started on ART and a higher proportion received key interventions.
Strengths and limitations of this study
This was a pragmatic evaluation in a routine service setting.
The intervention was implemented as part of routine health service delivery by existing clinical staff.
Routine data collection systems do not link testing and HIV care data, preventing an evaluation from testing to initiation.
The evaluation focuses on those with a known status, rather than new testers, those with tuberculosis or those who are pregnant.
The evaluation relies on intermediate outcomes, that is, initiation on ART, rather than long-term outcomes, such as mortality.
There is a lack of information on those requiring long-term follow-up but not ART.