HIV as a chronic disease: Dealing with lifelong treatment in Africa

In these countries, HIV care services were decentralized to peripheral health centers to facilitate access to lifelong antiretroviral therapy (ART). However, these peripheral centers are usually not equipped or adapted to deal with the additional work pressure and the number of additional patients. Malawi and Ethiopia are two examples of how this problem can be addressed delegating tasks to lower health cadres and creating new functions dedicated to HIV care, without compromising the quality of the care. However, strengthening health systems only is not enough to improve access to ART and retention in care: "As long as a patient is sick, a health center remains the most indicated place for treatment. However, you can't expect a fit HIV patient on ART to travel for two to three hours ever month just to fetch his or her pills. Furthermore, all peripheral health centers will be overcrowded and saturated within a short amount of time," says Rasschaert.

According to Rasschaert, treatment models of other chronic diseases, with the emphasis on 'self-management', can be applied to HIV care. Health care providers then no longer carry the main responsibility, but are essentially involved in teaching the necessary skills and knowledge to help patients cope with their disease themselves and to accompany them during this process. "This way people with HIV actively participate in the care of their chronic illness. At the same time, it reduces the work pressure in the health centers, providing more time for the health staff to care for the acutely ill."

Most of the chronic care models in developed countries can count on the support of strong health systems and multidisciplinary teams, which is rarely the case in countries with limited resources. That is why other support mechanisms, such as 'peer support' and social engagement, are so important. The community-based treatment model in Tete, Mozambique, is a good example of how patients can play an active role in their own care and the care of fellow patients. Groups formed by patients stable on ART ensure monthly access to antiretroviral drugs through a rotating drug collection system. They also offer support in therapy adherence and provide a protected environment in which patients can freely discuss their daily problems and challenges.

"HIV patients and their communities can play an important role in keeping people in treatment, but that's no excuse not to tackle the health system's problems. Stronger health systems and innovative patient-centered care should go hand in hand in lifelong HIV care," concludes Rasschaert.

Rasschaert made use of literature studies, analysis of routine data, retrospective cohort analyses and qualitative research methods to come to her conclusions.