In South Africa, quality of health care is directly related to the concept of patient-centred care. This is enacted by the Patients’ Rights Charter to safeguard against inequalities and Batho Pele (meaning “people first” and launched in 1997). It serves to transform the public health service delivery in healthcare. Factors which enable patient-centered care include:
- A positive work environment for staff
- Good leadership from managers
- Ongoing education of staff
- interdisciplinary teamwork
- removal of barriers (lack of resources, better streamlined administrative work, risk of medico-legal issues)
The Integrated Person centered health service approach does not distinguish older persons by specific conditions. Although HIV/AIDS carries a high morbidity and mortality especially in Advanced HIV Disease (AHD), we must still ensure that any condition an older person presents with must be treated and managed with the same relevant quality health care and services. Similarly, any older person experiencing socio-economic challenges must receive an equitable response irrespective of their condition. Staff and patients should be made aware of care pathways, and understand what referral mechanisms are available (see Referral Policy guidelines).
The HIV landscape
HIV is an ever-changing and fast-changing discipline of medicine. The landscape is being modified and aligned with best practices using the most efficacious medicines. Whilst all efforts are made to ensure this App uses updated and aligned material, revisions continue to occur.
1. Patient centric approach
- Always listen to your patient. If they are not improving, do not discard/disrespect/disengage with the symptoms they shared
- If laboratory results do not match the patient’s clinical picture, you may need to repeat the tests
- Ask the patient to share any plans to travel away or relocation. Sufficient medicines may be needed as well as a referral letter to the new clinic facility. A website is available with listings of all facilities in South Africa: www.healthsites.org.za.
- Ask the patient about support circles and ensure facility access appropriate eg does the patient have to travel far to reach your site and is there a nearer placed facility (ultimately this can also assist with better patient adherence).
- Has any circumstances at home or work changed since the last HCW visit (which may impact upon care).
2. Early warning indicators determine what symptoms are needing urgent management and refer to higher level of care if you are unable to support or diagnose the problem. Do not delay. Act on abnormal laboratory results.
3. Have a referral network that you can use. Have an HIV expert or skilled clinician you can speak to or call on your cellphone. Do not delay or wait if the patient deteriorating or not improving.
4. Public verses private sector. In South Africa, there are two main streams of healthcare. The public sector is where the majority (71%) of South Africans seek treatment, care and support for all conditions including HIV. A smaller percentage (27%) utilize the private sector if HIV positive and need care. Although there is considerable overlap between these two service providers of HIV care, there are many differences. The National Department of Health and Southern Africa HIV Clinicians Society (SAHCS) both have guidelines. Patient care should be guided by International best practices and World Health Organization (WHO). Patients move between these complimentary services, and services should not be seen as antagonistic.
A note on HIV guidelines
In parallel, two streams of HIV treatment guidelines have emerged over the years i.e. National Department of Health (NDoH) and the South African HIV Clinicians Society (SAHCS). Although there is much overlap and alignment between the two, the private sector is better financially supported and not constrained to use any drugs or tests at their disposal. The public health sector utilises more streamlined (and cost effective) approach. This flexibility allows for a more individualistic approach to private healthcare. Consequently, their HIV guidelines are often as aspirational and a golden standard to work towards as they cannot always be implemented in the public sector.
5. Universal Test and Treat: Many of the diseases and complications of AIDS can be prevented with ART especially if started early. Encouraging all patients to test, test early and start ART early is always the best route.

6. Every time your patient visits your clinic, it is a window of opportunity to ask a few simple questions and support your patient. For example, “has your partner/children been tested?”. Feedback is important so always share recent blood results with the patient. Place an emphasis on understanding the role of each patient’s HIV Viral Load (VL). The CD4 is helpful, but not always essential for ongoing HIV care especially if the CD4 count > 200 cell/mmᶟ.
Ensure that:
- every HIV-positive patient leaves with a follow-up appointment;
- The patient’s contact details in their clinical records are up to date so they can be contacted (urgently) for follow-up if any results are abnormal, eg. creatinine (Cr).
In the untreated patient (no ART), long standing infection with HIV causes a low-grade inflammation. Over time (HIV has a long, latent incubation period), the damage the virus causes may not be evident early in the history of the disease. During the intervening period (approximately 8 years), many patients may experience little or few problems.
Not all patients may present with all the usual signs and symptoms elicited in HIV negative patients. It is therefore important to always maintain a high index of suspicion and use your clinical experience. This always improves in time and use your support network to assist in clinical care eg. discuss the case with another experienced HIV clinician and call someone for advice.
The word “atypical” may sometime be used to describe the disease presentation of an HIV positive patient. Occult (hidden) disease may be harder to diagnose eg., tuberculosis. It may also result in a delayed or late diagnosis and treatment initiation. Remember that many of the diseases observed in HIV positive patients also occur in HIV negative patients. However:
- The symptoms may be of longer duration
- The signs may be more florid and severe, eg. molluscum contagiosum or the involvement of more than one dermatome in Shingles
- The problem may take longer to resolve despite treatment
- The disease may re-occur despite completion of adequate treatment
- Patient may present at an earlier age than normal, eg. cervical cancer
- Dual pathology – HIV positive patients may present with more than one diagnosis
- In TB, atypical presentation can include extra-pulmonary more commonly than pulmonary TB (PTB) compared to HIV negative patients
Always follow the fundamental steps to diagnosis:
- History
- Examination
- Special investigations
- Treatment