If you are HIV-positive and on medication, you will probably fare better with treatment from a rural hospital or clinic, possibly somewhere in KwaZulu-Natal. But avoid poorer municipalities and Limpopo.
A new study by researchers from Wits University and Boston University in the US found that while access to HIV services has improved, the quality of care varies hugely and is a barrier to reducing mortality.
While 96% of South Africans live within 10km of a health facility that provides antiretroviral treatment (ART), huge gaps in quality of care remain.
Between 2011 and 2016, the researchers analysed laboratory data on CD4 counts and HIV viral loads across 4,200 public healthcare facilities countrywide, except the Western Cape.
They found quality of care was higher in clinics versus hospitals, in rural health facilities rather than urban areas and in larger facilities. Quality was lower in areas with greater poverty.
KZN scored best on starting treatment on time, retaining patients in care, suppressing viral load and monitoring patients for treatment failure. Limpopo was ranked the worst.
Researchers said patients in poorer municipalities had lower quality of care, possibly due to poverty. The superior treatment in rural areas may be due to smaller populations and greater stability, they said.
They are convinced that targeting low-performing facilities for additional support could reduce the overall burden of disease, and understanding the differences in quality of care over time could guide interventions to improve health outcomes.
Improving quality of HIV care has been identified as the key step towards eliminating the epidemic.
In the highest quintile of facilities, 82% of patients achieved viral suppression, whereas only 60% were suppressed in the lowest quintile.
“If all facilities achieved viral suppression at levels equal to facilities in the highest quintile of quality, overall suppression would be increased by 22 percentage points in the lowest quintile and by 3.5 percentage points nationally,” lead researcher Jacob Bor from Boston University wrote in PLOS One.
“There has been growing interest in targeting the right programmes to the right people in the right places. Identifying which facilities are doing well and which are not is a key step in closing gaps in the HIV care cascade.”
With near-universal access to HIV treatment, researchers said the quality of care was likely to be among the most significant factors shaping the future course of local HIV epidemics and burden of disease.
In SA, an estimated 92% of medically preventable HIV deaths are because of poor quality of care and only 8% from lack of access.
While facilities that successfully diagnose new HIV infections, link people to care and retain them on therapy are likely to see HIV incidence fall in the communities they serve, researchers said poorer performance would result in persistent transmission, higher morbidity and mortality, and less financial protection for households.
“Measuring differences in quality of care across facilities is a critical step toward quality improvement,” they said.
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