Access to ARVs in South Africa Depends on Where You Live

In South Africa, the length of antiretroviral (ARV) prescriptions for people living with HIV often varies depending on the clinic they visit, reflecting disparities in access to multi-month dispensing. Ahead of World AIDS Day 2024, journalist Elri Voigt delves into the legal and policy issues surrounding prescription practices, highlighting why people living with HIV experience inconsistent treatment across different regions of the country.

The COVID-19 pandemic provided a unique opportunity to explore the impact of extended ARV prescriptions. In KwaZulu-Natal, as part of efforts to reduce crowding in clinics, some patients were issued 12-month prescriptions instead of the standard six-months. Researchers analyzing anonymized health data from over 27,000 HIV-positive individuals found that those receiving 12-month prescriptions maintained similar levels of adherence and viral suppression compared to those with six-month prescriptions. However, the extended prescriptions reduced clinic visits by half, suggesting that longer prescription durations can be both safe and beneficial for stable patients.

These findings support the differentiated service delivery (DSD) approach, which aims to tailor HIV care to individual needs, prioritizing intensive care for newly diagnosed or unstable patients while offering longer prescription refills to those who are stable. The World Health Organization (WHO) endorses this model, recommending that stable patients on antiretroviral therapy (ART) receive three- to six-month refills to reduce clinic visits and ease the burden on healthcare systems.

In South Africa, multi-month dispensing began in 2014 through the Centralized Chronic Medicines Dispensing and Distribution (CCMDD) system, allowing eligible patients to collect two-month supplies from designated pickup points instead of clinics. During the pandemic, the program expanded to offer 12-month prescriptions and three-month refills to more patients, demonstrating the potential to improve patient adherence while reducing healthcare facility congestion.

Despite policy shifts supporting multi-month dispensing, implementation remains uneven. According to Ritshidze, a community-led monitoring group, 68% of surveyed patients received a three-month supply of ARVs between July and August 2024. However, the percentage varied widely by province, with Limpopo achieving 79% compliance compared to just 21% in the Western Cape. Factors contributing to these disparities include stock management issues, clinician awareness, and inconsistent application of guidelines.

Stockouts remain a significant barrier, despite adequate national supplies. Poor supply chain management and conservative prescribing practices have led to fears of shortages, causing some clinicians to limit prescription lengths. Additionally, a lack of awareness among both healthcare providers and patients about multi-month dispensing policies further complicates access.

Advocates, including the Treatment Action Campaign (TAC), are calling for greater access to six-month refills, emphasizing the benefits for patients and the healthcare system. TAC General Secretary Anele Yawa argues that extending ARV refills can alleviate financial burdens for patients, reduce clinic congestion, and improve health outcomes by ensuring better adherence. TAC urges national and provincial health departments to finalize plans for broader six-month treatment supply rollouts by the end of the year, underscoring the need for improved planning, forecasting, and patient education.

Experts like Dr. Anna Grimsrud and Dr. Andy Gray agree that multi-month dispensing is a cost-effective strategy that can enhance patient outcomes and reduce healthcare system strain. Evidence from neighboring countries further supports the feasibility of scaling up six-month refills in South Africa.

Despite these promising developments, challenges remain. The National Department of Health has yet to provide a formal response to questions about its plans for multi-month dispensing, leaving uncertainty about the future of expanded ART access. However, the findings from studies and the push from advocacy groups suggest that extending ARV prescription lengths could play a pivotal role in improving HIV care in South Africa.