“The staff – from the security guard, to the clerks and even some of the nurses – they are not hungry for their jobs, you can see that. They shout at you, they leave the clinic to go buy magwinya and cold drinks even when the queues are long and they take their time. They also lose our files and don’t care for our privacy”

“I don’t default intentionally, but it costs me R24 to the clinic and R24 back for taxi, and it’s too far to walk. When you tell the clinic staff they don’t even care and they don’t try to help”

“There is always a high volume of people when I go there on Thursdays. And people are waiting outside and it’s dusty or cold. There are not enough chairs for everyone. They don’t have your file ready and it’s the security guard who takes our appointment cards and goes to find the files. And he is harsh, he screams at us and there’s no confidentiality – everyone knows you are there because you are HIV positive because he is shouting at us to stand in different queues”

The growing crisis in many of South Africa’s clinics has reached a point where patient care is being compromised and with it deepening worry that people living with HIV (PLHIV) are being pushed out of treatment. 

Allowing PLHIV to collect their medication refills outside of the clinic can improve this experience and reduce the risk of people disengaging from care. Decentralising medication refills — together with longer ARV refills as discussed in our last blog — can reduce how often PLHIV actually have to go to the clinic, reducing time spent in long queues, interacting with rude staff, or having their status involuntarily disclosed, as often reported through community-led monitoring.

Repeat prescription collection strategies, as they are known in South Africa, can simplify and adapt HIV services in ways that both serve the needs of PLHIV better and reduce unnecessary burdens on the health system. They should be much simpler and quicker systems than waiting in long clinic queues. 

There are three different types of repeat prescription collection strategies, the availability of which vary across provinces. PLHIV can use the facility pick-up point such as a fast lane or parcel collection room at a clinic. They can use an external pick-up point, which vary from place to place, including collection through Clicks or Dischem or other venues in the community such as a Pelebox or locker with a code sent to their phone. Others may opt for an Adherence Club, which meet in a health facility or a community venue, and offers additional peer support and treatment literacy education. 

Of the 381 clinics monitored through Ritshidze, our data shows that the following options are available:

• 366 clinics reported offering facility pick-up points (CCMDD parcel collection room, pharmacy, fast lane, fast track, Sha’p Left, ARV ATM, Pelebox/locker with code sent to phone)
• 331 clinics reported offering external pick-up points (pharmacy e.g. Clicks or Dischem or independent pharmacist, community venue e.g. church/library/other, from a mobile van, Sha’p Left, ARV ATM, Pelebox/locker with code sent to phone, Post Office)
• 108 clinics reported offering adherence clubs in the facility, and
• 74 clinics reported offering adherence clubs in the community.

The graphs below breakdown the types of facility pick up points and community pick-up points available by province through our monitoring. It is clear that the range of options needs to be expanded and made available nationally, not only in certain densely populated provinces like Gauteng. 

Overall, PLHIV were positive and satisfied with models of medication pick-up — showing that more PLHIV who are eligible should be allowed to use these options instead of going to the clinic. However many eligible PLHIV still do not use any of these options, and continue to collect their refills at the clinic after review by a doctor or nurse.

Adherence clubs are another important option. We have long been pushing for PLHIV to be able to join functional adherence clubs that not only make ARV collection quicker, but also allow PLHIV to join discussions as an opportunity to get the much-needed treatment literacy information and peer-support they may require to support them to remain adherent.

The data collected through Ritshidze shows mixed results around Adherence Clubs. 91% of adherence club members say they do make it quicker than waiting at the clinic and overall, PLHIV using clubs have a reasonably high satisfaction level. 

However 27% of adherence club members said that they did not get information about the importance of adherence, did not know, or only got information at the first meeting. 30% of PLHIV reported that club meetings lasted less than 30 minutes — which also points to clubs being a pick up point rather than a space for discussion and peer support. Just over 25% of adherence club members do not get peer support from adherence clubs (18.6% state they do not get support and 6.7% state they do not know if they get support which points to a lack of peer support). 

We maintain that functional adherence clubs play an important role in providing adequate treatment literacy information to ensure PLHIV stay on treatment and that these should not be simply cancelled in light of COVID-19. We need to work together to find safe solutions during the pandemic to ensure that PLHIV are still able to gain the benefits from these options. 

So what can the Department of Health and PEPFAR do?

• Get more people using repeat prescription collection strategies! Scale up to reach 60% of all PLHIV and ensure 25% are accessing treatment from a community-model and 20% from an Adherence Club.

• Carry out an audit into the functionality of adherence clubs together and urgently fix those that are not fulfilling their function properly (we outline the requirements for a functional adherence club in the People’s COP21)

This data set was presented to the Operation Phuthuma meeting on 5th March 2021. You can view the full presentation here. 

Please note: data related to the Western Cape has been excluded from the presentation and blog. This is whilst ongoing discussions with the Western Cape provincial department of health continue in order to allow for Ritshidze to proceed with monitoring. Until this negotiation has concluded, Western Cape DOH has refused to allow us to engage in monitoring or publish any findings.