Improving Access and Quality of HIV/AIDS Care in Eastern Cape, South Africa

Improving Access and Quality of HIV/AIDS Care in Eastern Cape, South Africa

Institute for Healthcare Improvement
Mhlontlo District, Eastern Cape, South Africa


IHI's global team is working with Collaborative sites in Mhlontlo District, Eastern Cape, South Africa to improve access to, and quality of, HIV/AIDS care.


Pierre Barker, MD, IHI Southern African Representative

Nupur Mehta, IHI Southern Africa Support Staff



The Mhlontlo district project is one of five pilot sites supported by IHI’s South Africa program to improve the system of comprehensive HIV/AIDS care. Mhlontlo is a poor rural district with a population of 200,000, an estimated HIV prevalence of 12.5 percent, and 2,500 people currently in need of antiretrovirals (ARV). The aim for this project is to improve the morbidity and mortality due to HIV/AIDS by:

  • Improving quality of care, including prevention, increasing access to services, and integrating HIV/AIDS-related services
  • Initiating 1,500 clients (85 per month) on antiretrovirals by December 2006



  • Cumulative number of clients on ARV
  • Monthly rate of initiation on ARV
  • Viral load (VL) suppression rates after 6 months and 12 months on ARV
  • Median CD4 count percent change after 6 months and 12 months on ARV


In this district, we used a collaborative approach to improving comprehensive HIV/AIDS care that promoted sharing of knowledge and empowerment of front-line health care providers to develop better systems of care. 


The change ideas for reducing mortality are centered on a model of comprehensive care which includes four components: prevention, diagnosis and referral, initiation of treatment, and chronic care.


Specific changes within each component are as follows:

  1. Prevention
    • Recruitment of pregnant mothers into prevention of mother-to-child-transmission (PMTCT) program by sharing of successful programs within the Collaborative
  2. Diagnosis and Referral
    • Capture of high-risk patients (TB, STI, inpatients) for HIV testing by introducing HIV counselors into these settings
    • Capacity-building of primary care clinics to do CD4 counting (locally designed solutions to transport barriers)
  3. Initiation of Treatment
    • Reducing systemic barriers to starting patients on ARV (bundling CD4 counts with HIV testing, decreased number of pre-ARV visits, bypassing the "selection committee," deferred home visits prior to starting treatment)
    • Capacity-building of primary care clinics to do pre-ARV preparation by transfer of skills within the Collaborative
  4. Chronic Care
    • Capacity-building of primary care clinics to accept down-referral patients through collaborative learning








Summary of Results / Lessons Learned / Next Steps


The Mhlontlo district experienced a significant increase in the number of clients who were initiated on antiretrovirals each month.  Since patients with symptomatic AIDS have a predicted two-year mortality of 80 percent, these interventions to date have resulted in at least 200 lives saved. This program is on target to reach its stated aim of initiating 85 new clients on ARVs per month, which will result in 900 lives saved by December 2006. 


These changes were sustained through a transition period which involved withdrawal of intensive IHI support and transfer of improvement skills to local health care providers. 


Next Steps

  • Inclusion of all 25 primary care clinics in the District into the comprehensive HIV/AIDS program
  • Down-referral of chronic stable ARV patients into the primary health care network
  • Complete transition of improvement process to local health care providers
  • Replication of model to three adjacent districts within the next 24 months



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