ENHANCE: Evaluating South Africa’s National Adherence Guidelines

Retention in HIV care and adherence to HIV treatment have long been identified as areas of concern in care and treatment programs in sub-Saharan Africa with numerous publications showing these indicators to be below national and international targets in most countries. To deal with this issue, in 2015 South Africa began rollout of National Adherence Guidelines for Chronic Diseases (HIV, TB and NCDs) to attempt to improve retention and adherence for HIV care and other chronic diseases. Guidelines called for a “minimum package” of eight interventions that described the implementation of Differentiated Service Delivery for HIV care. As part of the rollout, South Africa’s National Department of Health randomly allocated 12 primary health clinics in four provinces to receive the interventions with 12 additional randomly allocated clinics delaying implementation to be able to serve as control clinics.

ENHANCE was a five-year project (2014-2018) that the World Bank and South Africa’s National Department of Health implemented with Boston University (BU) and the Health Economics and Epidemiology Research Office (HE²RO) serving as academic partners to evaluate the program. The study took advantage of the cluster randomized rollout and all evaluations used data routinely collected by the clinics for study evaluations.

This team evaluated the effectiveness of five of the eight interventions in the minimum package: 1) fast track initiation counseling for patients eligible for antiretroviral therapy; 2) enhanced adherence counseling for unstable patients on HIV treatment; 3) adherence clubs for stable patients on HIV treatment; 4) decentralized medication delivery for stable patients on HIV treatment; and 5) early tracing of all patients who miss an appointment by two weeks. We also conducted qualitative interviews with patients and providers to understand how the interventions were implemented to identify ways to improve these outcomes. We also described the cascade of care for tuberculosis, diabetes and hypertension as part of this project.

Publications and Documents

Fox MP, Pascoe S, Huber AN, Murphy J, Phokojoe M, Gorgens M, Rosen S, Wilson D, Pillay Y, Fraser-Hurt N. Short-term outcomes from a cluster randomized evaluation of adherence clubs as part of differentiated HIV care in South Africa.  J Acquir Immune Defic Syndr 2021; online ahead of print.

Larson BA, Pascoe S, Huber A, Long L, Murphy J, Miot J, Fraser-Hurt N, Fox MP, Rosen S. Fast-track treatment initiation counselling in South Africa: a cost-outcomes analysis. PLOS One 2021;16: e0248551.

Larson BA, Pascoe S, Huber A, Long L, Murphy J, Miot J, Fox MP, Fraser-Hurt N, Rosen S. Will differentiated care for stable HIV patients reduce healthcare systems costs? J Int AIDS Soc 2020; 23:e25541.

Pascoe S, Scott NA, Fong RM, Murphy J, Huber AN, Moola A, Phokojoe M, Gorgens M, Rosen S, Wilson D, Pillay Y, Fox MP, Fraser-Hurt N. “Patients are not the same, so we cannot treat them the same”- A qualitative content analysis of provider, patient and implementer perspectives on a differentiated service delivery model for HIV treatment in South Africa. J Int AIDS Soc 2020; 23:e25544.

Pascoe S, Fox MP, Huber A, Murphy J, Phokojoe M, Gorgens M, Rosen S, Wilson D, Pillay Y, Fraser-Hurt N. Differentiated HIV care in South Africa: the effect of fast-track treatment initiation counselling on ART initiation and viral suppression as partial results of an impact evaluation on the impact of a package of services to improve HIV treatment adherence. J Int AIDS Soc 2019; 22:e25409.

Fox MP, Pascoe S, Huber AN, Murphy J, Phokojoe M, Gorgens M, Rosen S, Wilson D, Pillay Y, Fraser-Hurt N. Adherence clubs and decentralized medication delivery to support patient retention and sustained viral suppression in care: Results from a cluster-randomized evaluation of differentiated ART delivery models in South Africa. PLOS Med 2019; 16(7): e1002874. PMID: 1002874.

Fox MP, Pascoe S, Huber A, Murphy J, Phokojoe M, Gorgens M, Rosen S, Wilson D, Pillay Y, Fraser-Hurt N. Effectiveness of interventions for unstable patients on antiretroviral therapy in South Africa: Results of a cluster randomized evaluation. Trop Med Int H 2018; 23:1314-1325. PMID: 30281882.

Fox MP, Pascoe S, Huber A, Murphy J, Phokojoe M, Gorgens M, Rosen S, Wilson D, Ndhlalambi M, Pillay Y, Fraser-Hurt N. Evaluation of the National Department of Health’s National Adherence Guidelines for Chronic Diseases in South Africa using routinely collected data: a cluster randomised evaluation. BMJ Open 2018; 8: e019680.

Huber AN, Pascoe S, Fox MP, Murphy J, Mphokojoe M, Gorgens M, Wilson D, Pillay Y, Fraser-Hurt N. Leveraging routine data in impact evaluation: Understanding data systems in primary healthcare prior to a matched cluster-randomised evaluation of adherence guidelines in South Africa. S Afr Med J. 2022 Oct 5;112(10):819-827. doi: 10.7196/SAMJ.2022.v112i10.14909.