Despite Widespread Access, Quality of HIV Care Differs Across South African Facilities

By Emanne Khan

South Africa is home to the world’s largest population of individuals living with HIV, numbering nearly 8 million, according to the Center for Strategic and International Studies. South Africa also administers the world’s largest public HIV treatment program, which serves a patient population between 4-5 million people. 

Despite the scope of the nation’s HIV treatment program, gaps persist in the quality of care administered across facilities. In a March study published in the journal of PLOS Medicine, Human Capital Initiative Core Faculty Member Jacob Bor and nine coauthors analyze data from South Africa’s National Health Laboratory Service, finding that clinics, larger facilities and rural facilities offer the highest-quality care.

Bor and coauthors emphasized that access to HIV care does not guarantee quality. According to the authors’ calculations, 96 percent of South Africans live within ten kilometers of a health facility providing antiretroviral therapy (ART), the main method doctors use to treat and manage HIV. However, per a 2018 article from Lancet Global Health, “poor-quality care is now a bigger barrier to reducing mortality than insufficient access” in low- and middle-income countries, like South Africa.

What measures separate high-quality care from poor-quality care? Bor and coauthors choose to focus on patient outcomes, rather than variables such as facility staffing levels and physical infrastructure. Measures of quality based on outcomes “focus attention on what really matters and offer a common benchmark to which all facilities can aspire,” they wrote. 

To obtain the data necessary for their analysis, the researchers drew on South Africa’s National Health Laboratory Service Corporate Data Warehouse (CDW). The CDW stores a number of datapoints that reflect treatment outcomes for South Africa’s HIV patients, including patient CD4 counts (a type of white blood cell that HIV targets and destroys) and viral loads (the amount of virus present in a patient’s blood) throughout the duration of treatment. 

For each of 3,265 healthcare facilities involved in South Africa’s public sector HIV program, Bor and coauthors defined high-quality HIV care and treatment based on six total measures tracked from 2011-2015. The measures include the median CD4 count for patients at each facility; the facility’s success in the viral suppression of HIV among its patients; and patient retention rates. The researchers combined the six measures into a single quality score for each facility.

The study was a collaboration between researchers at Boston University, the Health Economics and Epidemiology Research Office (HE2RO) at the University of Witwatersrand, and the National Health Laboratory Service, both in South Africa.

Main findings

On average, HIV treatment quality improved for the facilities involved in the study. From 2011 to 2015, the average proportion of patients retained 12 months after presentation increased from 42 percent to 47 percent, CD4 recovery increased from 39 percent to 60 percent and viral suppression increased from 66 percent to 79 percent. However, despite the general improvements, the researchers noted that not all facilities performed equally.

During the years of focus, quality was higher at facilities with larger patient populations; at clinics versus hospitals; at rural facilities; and in wealthier municipalities. The researchers posited that part of the difference could be driven by lower patient retention rates at hospitals, perhaps due to their sicker patient populations and higher mortality rates. The researchers add that “Interestingly, quality was highest at primary care clinics in rural areas, perhaps because the patient population in these areas is more stable.”

Notably, the researchers found “evidence that quality is clustered geographically across space.” Per their findings, the eastern province of KwaZulu-Natal contains the country’s highest-quality facilities, and Limpopo in the north contains the lowest. Figure 1 below plots the quality of HIV care by region, with better-performing facilities marked in green and lower-performing facilities in red. 

Figure 1: Geographic variation in quality of care, 2011-2015

Source: PLOS Medicine.

Notably, the racial makeup of each municipality was not significantly associated with the quality of its HIV treatment facilities. According to the authors, race, and in particular the proportion of a municipality that is Black, is a topic “of particular concern when thinking about health inequities in South Africa.” In this study, the authors found that a municipality’s poverty rate is a much stronger predictor of its HIV facility quality than its racial demographics.

Policy implications

Bor and coauthors’ findings represent an important contribution to the field of HIV treatment scholarship. Their methodology for assessing facility quality proves highly reliable and their assessment can be used to guide future quality improvement efforts, as “understanding differences in quality of care across time and space could guide interventions to improve quality and achieve better and more equitable health outcomes.” 

The authors acknowledged their reliance on laboratory data as the basis for assessing facility quality presents some limitations, and “laboratory results are but one vantage point on quality of care.” Additionally, because the authors did not observe more frequent clinic visits or pharmacy pickups, they “may miss patterns where patients cycle in and out of care between laboratory results” and that, “further linkages of laboratory data with clinical and pharmacy data could yield further quality indicators—such as visit and medication pickup adherence—and could improve the accuracy and precision of the overall quality-of-care score.”

Additional research could also address which facility “inputs and processes” affect treatment quality; whether patients migrate from lower-quality facilities to higher-quality ones; and how quality differentials impact population health outcomes.

Bor and colleague Dr. Dorina Onoya of the University of Witwatersrand are working to integrate this outcome-based quality measure with the “Ideal Clinic” initiative, an ongoing effort to measure quality of inputs and processes.

Bor and coauthors envision a future in which their findings might be shared with facilities in order to kickstart quality improvement efforts. According to the 2018 Lancet Global Health report, in South Africa, “an estimated 92 percent of medically preventable HIV deaths are due to poor quality of care and just 8 percent from lack of access.” 

As their study suggests, shifting the focus of treatment from access to quality could be the key to reducing the burden and impact of HIV worldwide.