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Addressing disengagement from HIV healthcare services in Khayelitsha, South Africa, through Médecins Sans Frontières' Welcome Service approach: comprehensive clinical and patient-centered care

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BACKGROUND: Many people living with HIV experience competing psychological and socioeconomic challenges that impact their ability to remain on antiretroviral therapy (ART) lifelong, magnified by disorganized clinic systems, stigmatizing attitudes towards 'difficult' patients and delays in clinical management. Recognising the need to tackle these challenges, Médecins Sans Frontières and the Western Cape Department of Health developed a differentiated service to support long-term ART engagement by creating a more streamlined and client-centered approach to care.
DESCRIPTION: The Welcome Service, implemented at a primary healthcare clinic Khayelitsha, a low-income area in South Africa with a high HIV prevalence, focused support on patients returning after disengagement (interrupted ART or missed appointments). Clinic services were re-organised and training conducted to (1) reduce delays in ART re-initiation and unsuppressed VL management; (2) re-organise triage to streamline services; (3) improve counseling with additional tools to manage barriers to engagement; and (4) address negative healthcare worker (HCW) attitudes and authoritarian behaviours.
LESSONS LEARNED: Re-organising triage prevented returning patients from waiting longer to be seen than other patients and flagged acutely unwell patients requiring urgent care. Training provided HCWs with knowledge and tools to manage 545 disengaged patients (July 2018-October 2019) through focused identification of client-specific challenges. However, high staff turnover set back gains, highlighting the difficulty with sustaining a programme long-term. This reflected in modest retention at 5-12 months (60%) and poor one-year VL completion (49%) and suppression (51% of complete, <50 copies/ml). A reluctance to change clinical practice with local guideline updates was noted, largely due to staff motivation and buy-in. Addressing HCW's stigmatizing attitudes proved challenging and required constant re-engagement. A parallel programme (Risk of Treatment Failure), supporting clients with detectable VLs, complicated Welcome Service rollout. Recognising that both programmes supported clients having difficulty with ART, the two were merged to provide one service for 'struggling' patients.
CONCLUSIONS: Modest retention and VL suppression were seen amongst this group, where poorer outcomes may be expected than amongst stable clients on ART, highlighting the need to continue developing scalable strategies to tackle disengagement. As we continue rolling out this intervention, adaptation to clinic needs is essential to long-term success and sustainability.