The national provision of antiretroviral (ARV) medication in the public sector has been an unexpected success, despite negative expectations ahead of the programme’s launch in March 2004.
Current estimates are that between 5-million and 6-million people in South Africa are HIV infected. Assuming disease progression takes an average of ten years, for the next decade approximately 500 000 people will need to start ARVs every year.

The government’s National Strategic Plan published during 2007 set the goal of having 2-million people on treatment by 2011. This would represent a 500% increase in service delivery compared to the situation now.
If this national government target is achieved it would represent one of the most dramatic responses to an epidemic in the history of infectious diseases. Even this ambitious target would still leave a treatment gap with many people in need of ARVS not receiving them. Every individual not reached represents a preventable death.

There are two complementary ways of achieving the required scale-up in-patient numbers:

• Increase the number of sites initiating ART by expanding the kind of institutions that can start patients on treatment and
• Down-referring stable patients to a lower level of care using trained non-doctor healthcare workers.

The theoretical basis to down-referral

The current initiation sites are largely hospital based and have demonstrated two trends, particularly over the last three years. Firstly staff have generally attained high levels of expertise and competence at initiating and monitoring patients on ARVs. Second, every ARV site of over two years’ standing is now at maximum capacity.
As patients become healthy on ARVs they pass to a maintenance phase of treatment and the care required from the institution is relatively minimal. However, these chronically sick but ‘healthy’ patients use up as much institutional resources as those who are ill and in need of more active care. While a ‘healthy’ patient will use relatively little clinical time, she will use the same time at registration, reception, routine observations, pharmacy and booking as the acutely ill. In addition, the crush of the ‘healthy’ makes the physical environment crowded and unpleasant for both staff and the ill patients.

The solution is clearly to move healthy patients settled on ARV treatment away from the initiation site to one more suited to their medical needs. This would increase capacity at the initiation site for ill patients as well as allowing chronic care sites to be better tailored to suit the needs of patients, for example, access to medication out of working hours. The services offered at a down-referral site could depend on the client base being served.

Mandatory features of a down-referral site:

• No doctor
• A nurse-run service: Nurse clinician or an ordinary nurse as the senior care provider dependent on services offered
• ‘Task shifting’: The allocation of tasks previously done by doctors or professional nurses to staff with less training (and lower salaries)
• No pharmacy involved : drugs are packed for patients at the initiation site and transported to the maintenance site
• Pharmacy storeroom to store drugs sent from initiation site

Optional features of a down-referral site:

• Facility for six monthly blood draws for monitoring
• Facility for interpretation of the blood drawn
• Either clinical review at every visit; or alternatively most visits are purely for drug collection, with clinical reviews at intermittent intervals.

The Right to Care model of down-referral

This model, by no means the only model in operation across the country, has a number of novel features, including:

• A paperless clinic at down-referral level with data flowing from a computer assisted clinic to a computerised data base at the initiation site and back again
• Well trained PHC sisters who maintain a high standard of clinical care, including the interpretation of routine blood monitoring tests and the repeat of prescriptions
• Patients at Right to Care down-referral sites will remain permanent patients of the down-referral clinic (they will return to the initiation site only when or if their medicines require changing to a different kind).
• Meticulous follow up of patients who miss appointments at the down-referral clinic via an SMS messaging service, phone calls and home visits.

Right to Care’s down-referral programme is headed up by Dr Dennis Rubel, who is based at the organisation’s head office alongside the Helen Joseph Hospital, Johannesburg.

Initial set of Right to Care down-referral clinics in Gauteng