Between HIV diagnosis and initiation of antiretroviral therapy: assessing the effectiveness of care for people living with HIV in the public primary care service in Cape Town, South Africa

OBJECTIVE To assess the quality of pre-antiretroviral therapy (ART) care in Cape Town and its continuity with HIV counselling and testing (HCT) and ART. METHODS The scale-up of the HCT, pre-ART and ART service platform and programmatic support in Cape was described. Data from the August 2010 routine annual HIV/TB/STI evaluation, which included interviews with 133 facility managers and folder reviews of 634 HCT clients who tested positive and 1115 clients receiving pre-ART HIV care, were analysed. RESULTS Historically, the implementation and management of pre-ART care has been relatively neglected compared with the scale-up of HCT and ART. CD4 counts were carried out for 77.5% of positive HCT clients, and 46.6% were clinically staged - crucial steps that determine the care path. There were gaps in quality of care (32.2% of women had a PAP smear), missed opportunities for integrated care (67% were symptomatically screened for tuberculosis) and positive prevention (48.3% had contraceptive needs assessed). Breaks in the continuity of care of pre-ART clients occurred with only 47.2% of eligible clients referred appropriately to the ARV service. CONCLUSION While a package of pre-ART care is clearly defined in Cape Town, it has not been fully implemented. There are weaknesses in the continuity and quality of service delivered that undermine the programme objectives of provision of positive prevention and timely access to ART.