State-of-the-ART Care: Revolutionizing Medication Delivery in Rural Settings with a Person-Centered Care Approach

As of 2022, there were 7.8 million people living with HIV in South Africa. HIV prevalence in South Africa varies geographically, with the KwaZulu-Natal province continuing to have the highest HIV prevalence in the country and rural formal farming communities reporting a higher HIV prevalence than urban areas. It is important to identify strategies that can help close the remaining gaps in HIV treatment and care in South Africa. Until a cure for HIV is available, reliable access to antiretroviral therapy (ART) is needed to maintain HIV viral suppression for people living with HIV. The current standard-of-care in South Africa to refill ART supply is for individuals to go in-person to clinics, with the duration of ART refills limited to one to three months for most individuals. Resupplying ART through community-based venues, such as home delivery, can effectively increase ART coverage and adherence compared to clinic-based care while decongesting clinics for attention to acute patients. Home-delivered ART and monitoring could potentially offer cost savings compared to clinic-based care in terms of financial costs and environmental costs. I investigated the differential COVID-19 pandemic impact for home-delivery of ART compared to standard clinic-based care among people living with HIV in rural South Africa and compared the environmental and cost impacts of the two ART delivery models. In Chapter 1, I observed no difference in the self-reported number of missed ART doses by method of ART refill (home-delivered vs. at clinics) when comparing between or within time periods during the first COVID-19 wave in South Africa. In Chapter 2, I found that incremental CO2 emissions were higher for participants receiving home-delivered vs. clinic-based ART refills in rural South Africa but could be offset by six- or 12-month refills (and reducing delivery frequency) and/or switching to electric delivery vehicles, decreasing the impact on the environment. In Chapter 3, I found that the average annual cost per client and average annual cost per client virally suppressed of implementing a home-delivered ART intervention was higher than the cost of clinic-based ART refills and care from the payer perspective in the as-observed scenario. Personnel costs were the largest cost for home-delivered refills while ART drug costs were the largest cost of clinic-based refills. When provided at scale, home-delivered ART in a rural setting not only offers clinical benefits for a hard-to-reach population but is also comparable in cost to the provincial standard of care. While fee for home delivery was demonstrated to be an effective ART refill method for achieving viral suppression compared to clinic-based refills in the Deliver Health Study, home-delivered ART was found to be more environmentally and financially costly compared to standard clinic-based refills in the as-observed scenario, and did not have a significant effect on the risk of missing ART doses during the first COVID-19 wave in South Africa. However, when home ART delivery is implemented at-scale and with multi-month refills, there are potential cost- and environmental savings relative to the standard clinic-based care. This research provides novel insights to the financial costs and environmental impact associated with implementing home-delivered ART refills and monitoring in rural South Africa, a relatively new differentiated service delivery method which could be scaled up more widely in an effort to reduce physical access barriers for people living with HIV and to offer clients more resupply options that could better suit their lifestyle preferences.