Background: In 2016 South Africa adopted WHO recommendations of ART regardless of CD4 count for PLHIV. In 2016, ART coverage in South Africa was estimated at 56%. A shift toward increased uptake of ART at higher CD4 counts is required. Historically, health-messaging about starting ART have highlighted side effects, risks of acquired resistance, and triage of available treatment. CD4-count eligibility criteria and pre-ART counselling has reinforced a perception that PLHIV must be ''sick enough'' to initiate ART. A shift in messaging is critical to increase uptake and ensure adherence. The study provides insight on ART messaging pre-national ART policy shift. How can we explain this policy shift to PLHIV and motivate them to initiate?
Methods: HPTN 071 (PopART) was a community-randomised trial in Zambia and South Africa. Patients at three health facilities in one arm of the trial in the Western Cape Province, were eligible for ART regardless of CD4 count outside of guidelines between June 2014 and September 2016. We conducted 134 randomly selected clinical patient folder reviews to characterise the sociodemographic profile of ART initiators under these conditions. We interviewed key informants (nurses, counsellors, post basic pharmacist assistants, data capturers and health management staff; n=12) about their experiences explaining initiating ART at high CD4 counts. The evaluation design was exploratory through case descriptions.
Results: The mean age of patients initiating ART at CD4 count >500 was 34.6 (range: 17-65; SD = 9.13) and most were women (74.7%), married (65.3%), and employed (42%). These sociodemographic characteristics were very similar to patients initiating ART at CD4 counts ≤500. Key informants indicated no radical shift was necessary to explain ART regardless of CD4 count. Rather, they (i) used a variety of metaphors to emphasize the importance of building a strong foundation and not waiting until HIV weakened the body, (ii) reiterated that ART prevents opportunistic infections, and (iii) emphasized that management of HIV through ART is comparable to other chronic diseases.
Conclusions: Motivating patients to initiate ART at high CD4 counts is possible even in high burden settings. Messaging about reduced risk of onward transmission was not a core component of health workers'' narratives.