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HIV care and antiretroviral treatment (ART) provision is largely hospital-based with an over-reliance on doctors. Existing ART sites are reaching capacity and are increasingly unable to initiate new patients and also see follow up patients. In response, the Reproductive Health and HIV Research Unit (RHRU), has supported the KwaZulu-Natal provincial Department of Health with developing a model to decentralise services to primary health care (PHC) level. The programme has been in operation since 2006, and currently nine ART initiation sites down refer stable patients to 24 PHC clinics. Data on patient numbers, treatment outcomes and patient retention rates were collected through a file audit of 2071 adult patient files and analyzed. Results indicate that a file audit is a feasible mechanism to provide this data and can be used to identify gaps and improve quality of care. PHC sites in resource-constrained settings are able to manage stable patients on ART; however, sites need support with monitoring and evaluation and with tracking patients that have been down referred. In terms of quality of care, PHC sites need to ensure that clients receive CD4 count tests and viral load monitoring at six monthly intervals to ensure that treatment failure does not go undetected. Patients suspected of experiencing adverse events or treatment failure appear to be managed according to standard operating procedures, but there is a need to ensure that adverse events are clearly documented in patient files.

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Using a File Audit to Evaluate Retention in Care and Patient Outcomes in a Programme to Decentralise Antiretroviral Treatment to Primary Health Care Facilities in a High Prevalence Setting in KwaZulu-Natal, South Africa