In February 2024, the HSRC launched a mobile smart locker system, providing a quick, efficient, and discreet method for patients to collect their medicine parcels in uMgungundlovu, KwaZulu-Natal. This medication dispensing system has been deployed as part of a research project aimed at finding alternative and more effective ways to improve antiretroviral therapy (ART) uptake in under-serviced communities. The researchers are also testing other approaches, such as ART home delivery and incentivising clinic visits through a lottery system. Antoinette Oosthuizen, Xolani Ntinga and Malwande Ntlangula report.
Every month, millions of South Africans queue for hours to pick up their chronic medicine from local clinics. These trips have attendant costs for transport, food purchases for the day and, for some, a day’s wages for not being at work. In small communities where health workers are neighbours, those fetching antiretroviral treatment (ART) may also fear their HIV status being revealed before they are ready. Or, if they missed visits and interrupted their treatment, they dread a public scolding by healthcare workers.
Defaulting on ART has dire consequences. ART reduces the amount of HIV in the body (viral load). Having less than 1,000 copies of HIV/ml blood means viral load suppression has been achieved, and the person’s chance of getting ill or transmitting HIV to another person is greatly reduced.
Photo: HSRC
Results from the recent Sixth South African National HIV, Prevalence, Incidence and Behaviour Survey (SABSSM VI) show that South Africa has made significant progress toward its 95-95-95 UNAIDS targets – that by 2025, at least 95% of all people living with HIV will know their HIV-positive status, 95% of those who know they have HIV will be on ART, and 95% of all those on ART will have achieved viral load suppression. SABSSM VI shows that in 2022, 89.6% of people living with HIV aged 15+ years knew their HIV-positive status. Of those who knew their HIV-positive status, 90.7% were on ART, and, overall, 93.9% of those on ART had achieved viral load suppression. This was an improvement compared to 2017, when the UNAIDS target was 90-90-90 but South Africa achieved 85-71-87. The increased uptake can be attributed to new guidelines that make provision for everyone requiring ART to be given it immediately, regardless of their clinical status. Previously, their CD4 count needed to be below 500 cells/mm3 to be included.
“This success underscores the importance of tailoring interventions based on evidence,” says Professor Alastair van Heerden, director of the HSRC Centre for Community-based Research in Sweetwaters, KwaZulu-Natal.
“To maintain and accelerate progress, we must also continue to adapt and respond to the nuanced needs of under-serviced communities, for example, through community-specific strategies to improve ART uptake, as demonstrated by innovative interventions like dispensing medicine via mobile smart lockers and many other strategies researchers are testing in the field.”
Previous attempts to improve patients’ ART uptake and adherence have included ART dispensing via clinic-based medicine lockers, lottery incentives, as well as home and community visits.
No one-size-fits-all approach
In a 2017–2018 study in rural KwaZulu-Natal, HSRC researchers partnering with colleagues from the University of Washington tested the impact of lottery incentives that rewarded positive health choices (e.g. taking up ART) in a group of men. The lottery prizes were a mobile phone, data or a gift card valued at R1,000. The researchers found that lottery incentives increased ART initiation in the short term, but did not lead to long-term viral suppression.
Research testing community– and home-delivery systems also showed benefits. While they are more costly for the healthcare system, the researchers believed the health benefits for some people may outweigh the increased cost.
In 2019, HSRC researchers conducted a qualitative study in KwaZulu-Natal to investigate the acceptability of a fee for home delivery of ART. The participants were positive about having ART home delivered, as it would spare them hours queueing at clinics. While some felt high unemployment in the community could hinder a fee-paying system, others reckoned patients would have to incur costs for travel and food when visiting the clinic anyway. However, some participants also feared accidental disclosure during home delivery, especially if they had not disclosed their HIV status to their immediate families and partners.
Realising that a one-size-fits-all approach might not work for everybody and that policymakers and programme managers needed to understand what motivated different groups of patients to take up ART and adhere to their treatment, the HSRC has embarked on a project to test various types of ART care using an adaptive treatment model.
HSRC response: Adapting and scaling up forms of care
Since November 2021, HSRC researchers have been working on a research study using an adaptive treatment strategy to test these alternative forms of care. The idea is to adapt and scale up HIV services depending on the needs and responses of people living with HIV, specifically individuals who have not done well taking up and adhering to ART via clinic visits.
Those who take part in the Sequential Multiple Assignment Randomized Trial (SMART) are people living with HIV from the greater Edendale area in the Umgungundlovu District of KwaZulu-Natal, South Africa, who have not managed to achieve viral suppression in existing clinic systems, or have not engaged in care for at least six months.
The first group has been offered standard clinic care, half of them with a lottery incentive motivating them to access care and the other half without. To be eligible for the lottery entry (a R1,000 cash prize), participants in that group need to complete their clinic visits and adhere to ART.
After six months, participants from this group who still have detectable viral loads or are not in care are further randomised to either continue in their original group, or be in the smart locker ART pickup group or the home-delivery group.
To assist patients in the smart locker arm, a mobile unit with smart lockers is transported to communities, where the participants can fetch their prepacked ART. Unlike previous locker systems at clinics, these lockers are accessible 24 hours a day while based in the area, so that participants can fetch their medication outside working hours and at weekends. Participants in the home-delivery arm receive their ART at home or at a location of their choice, such as a community centre.
These participants are then followed up for another year. After the 18-month participation period, the researchers will compare the different groups, looking at participants’ levels of viral load suppression, the extent to which they completed clinic visits and received their ART refills, and how long it took them to start their treatment.
At the time of writing, 911 people had been enrolled in the SMART-ART study, each person to be followed for 18 months. More than one-third had completed their participation, and researchers hope to conclude the study in the second quarter of 2025.
Envisaged outcomes and impact
The findings of this study will shed light on the feasibility of these ART delivery interventions for different groups of people who were previously hesitant to take up care.
“The SMART-ART study is an example of the flexibility and responsiveness required in modern HIV care,” says Van Heerden. “By tailoring interventions like the lottery incentive, smart locker system, and home delivery of ART, we aim to meet the diverse needs of individuals who have struggled within the traditional clinic-based model. This approach addresses barriers to access and adherence, and seeks to build a more inclusive and effective healthcare framework that can adapt to the evolving dynamics of communities and the individuals within them.
“The insights gained will be crucial for policymakers and programme managers in designing effective and culturally sensitive interventions,” adds Van Heerden. “The ultimate goal is to establish scalable and sustainable models of HIV care that can be implemented across various regions, ensuring that no one is left behind in our quest to combat the HIV epidemic.”
Research contacts: Prof. Alastair van Heerden (director), Xolani Ntinga, (research project manager) and Malwande Ntlangula (communications officer) at the HSRC Centre for Community-based Research in Sweetwaters, KwaZulu-Natal
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