Evaluation of the impact of PEPFAR transition on retention in care in South Africa’s Western Cape

Background: Research on the impact of the PEPFAR transition in South Africa (SA) in 2012 found varying results in retention in care (RIC) of people living with HIV (PLWH). Objectives: We investigated the factors that impacted RIC during the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) transition in Western Cape, South Africa in 2012. Methods: We used aggregate data from 61 facilities supported by four non-governmental organizations from to 2007–2015. The main outcome was RIC at 12-months after antiretroviral therapy initiation for two time periods. We used quantile regression to estimate the effect of the PEPFAR pull-out and other predictors on RIC. The models were adjusted for various covariates. Results: Regression models (50th quantile) for 12-month RIC showed a 4.6% (95%CI: −8.4, −0.8%) decline in RIC post direct service. Facilities supported by Anova/Kheth’impilo fared worst post PEFPAR; a decline in RIC of (−5.8%; 95% CI: −9.7, −1.8%), while that’sit fared best (6.3% increase in RIC; 95% CI:2.5,10.1%). There was a decrease in RIC when comparing urban to rural areas (−5.8%; 95% CI: −10.1, −1.5%). City of Cape town combined with Western Cape Government Health facilities showed a substantial decrease (−9.1%; 95% CI: −12.3, −5.9%), while community health clinic (vs. primary health clinic) declined slightly (−4.4; 95% CI: −9.6, 0.9%) in RIC. We observed no RIC difference by facility size and a slight increase when two or more human resources transitioned from PEPFAR to the government. Conclusions: When PEPFAR funding decreased in 2012, there was a decrease in RIC. To ensure the continuity of HIV care when a major funder withdraws sufficient and stable transition resources, investment in organizations that understand the local context, joint planning, and coordination are required.


INTRODUCTION
Data 1 3 2 The aggregate data used for this study was retrieved from the WCGH's HIV data system, 1 3 3 (Tier.net) (22). The primary purpose of Tier.net is to manage the HIV program at a facility level. Data from Tier.net aggregated at the facility level were collected for 61 health facilities Care (n=5); and (4) TB, HIV/AIDS, Treatment Support, and Integrated Therapy (that'sit) (n=11). There was a fifth category in our analysis of Anova/Kheth'impilo, as these two NGOs  The four NGOs used in this study were the main NGOs working in the Western Cape that  (Table 1). Note that Right to Care's timeline was 1 4 7 slightly later, from 2009 to 2014. During this time, funding was used to scale up, support, and 1 4 8 expand access to HIV services, including HIV testing and counselling, treatment, prevention of 1 4 9 mother-to-child transmission, combination prevention and screening, and treatment of 1 5 0 tuberculosis. In 2013, that'sit, Right to Care and Kheth'impilo received extension funds to close . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted April 14, 2023. ; province. As noted, Anova and Keth'impilo both worked in the Metro District, supporting seven 1 5 5 of the same health facilities. The main outcome of interest was RIC at 12 and 24 months after ART initiation in each definition for RIC among adults (age >15 years) is as follows: Total on treatment includes HIV clients who are transferred to the health facility via a 1 6 5 formal or silent transfer. Mortality was included in patients who stopped treatment. We 1 6 6 conducted a sensitivity analysis by adding death to the definition, and the results did not change. vs. rural), number of job posts transferred from PEPFAR NGOs to government (categorized as 1 7 0 <1 and >2), facility type (central day clinic (CDC), community health clinic (CHC), and primary 1 7 1 health clinic (PHC)) and government (City of Cape Town, Western Cape Government and a 1 7 2 combination where they both overlapped) and NGO (Anova, Anova/Kheth'impilo, Kheth'impilo, that'sit and Right to Care). RIC for each health facility supported by Anova,  Retention in Care = .
CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

(which was not certified by peer review)
The copyright holder for this preprint this version posted April 14, 2023. ; Right to Care became active two years later, the average RIC cut-off was 2009 to 2012 1 7 7 (PEPFAR direct service) and 2013 to 2015 (post-PEPFAR direct service).

7 8
Simple descriptive statistics were used to report the characteristics of the study sample 1 7 9 and were stratified by NGO. We graphically displayed trends in 12-and 24-month retention, loss 1 8 0 to follow-up (defined as clients who have not visited the health facility for more than 90 days),  Quantile regression was used to estimate the associations between PEPFAR pull-out and 1 8 4 changes in 12-month retention in care at the 25 th , 50 th and 75 th quantiles adjusted for covariates. The models contain the dependent variable (12-month retention), conditional on time (years), 1 8 6 plus an indicator variable for PEPFAR pull-out (set to 0 for each year during PEPFAR funding 1 8 7 and set to 1 for years post-PEPFAR), an interaction term between these two variables to display The 61 health facilities included in the study sample were predominately WCGH owned 2 0 2 (77%), with a total of 190,343 patients, and equally split between rural and urban areas (Table 2).

0 3
The majority of the clinics were supported by Anova (n=23, 38%) and Kheth'impilo (n=15, 2 0 4 25%), while Right to Care had the lowest number (n=5, 8%). ART cohorts gradually increased in  The mortality rate of the study sample substantially decreased post the PEPFAR transition,  (Figure 1). This is most likely due to 2 1 8 a delay in reporting of mortality, as previous research shows 50% of loss to follow-up is due to . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

5 7
Owing to PEPFAR's transition strategy, health facilities lost close ties with the community, and Therefore, our results may not be generalizable to other provinces and/or other sub-Saharan 3 0 5 African countries where PEPFAR was implemented. Second, our data was aggregate data that  . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

(which was not certified by peer review)
The copyright holder for this preprint this version posted April 14, 2023. ; confounding due to the inability to control for potential confounders due to missing information 3 1 4 at the facility level (i.e., transfers, employee turnover rate). We attempted to minimize 3 1 5 confounding by type of health facility by including only primary healthcare facilities (i.e., 3 1 6 clinics, community day centers, and community health centers) in our study. Our results show that when donor funding decreased, there was a decline in RIC of 3 1 9 patients in HIV care post-PEPFAR compared to the PEPFAR direct service era. To ensure that 3 2 0 the RIC is high, the system needs to minimize loss to follow-up. Support from different 3 2 1 government bodies and the size of health facilities had no effect on RIC, although additional 3 2 2 human resources in the system and support from NGOs with a history in the province assisted in       . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

(which was not certified by peer review)
The copyright holder for this preprint this version posted April 14, 2023. ; Figure 1. 12-month retention in care, loss to follow-up and death overlaid on total patients on ART at the start and end of the 12-month period.   is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

(which was not certified by peer review)
The copyright holder for this preprint this version posted April 14, 2023. is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

(which was not certified by peer review)
The copyright holder for this preprint this version posted April 14, 2023.

Right to Care
Overberg; Central Karoo CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

CC-BY 4.0 International license
It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

(which was not certified by peer review)
The copyright holder for this preprint this version posted April 14, 2023.