Impact case study database

Our REF2014 impact case study described how, in South Africa until 2013, our research led to delivery of PALSA, PALSA PLUS and Primary Care 101 [2.1-2.3], and enabled nationwide expansion of antiretroviral treatment for HIV based on STRETCH [2.4]. Since 2014, impact has evolved and expanded. The previous four interventions were incorporated into PACK, which was further developed and delivered throughout South Africa and internationally [5.1-5.7], while ART expansion continued in South Africa [5.8].

4.1 From Primary Care 101 to PACK in South Africa

Building on our evidence that Primary Care 101 guidelines and training, and their predecessors, led to improved management of TB, HIV, respiratory disease, diabetes, hypertension and cardiovascular disease, KTU developed Primary Care 101 into a comprehensive clinical decision support tool called PACK Adult (also called Adult Primary Care (APC)) [5.1,5.2]. PACK Adult and APC now cover the commonest and most important adult conditions, including 40 symptoms, and 20 communicable and non-communicable diseases. In 2015 the South African National Department of Health launched its Ideal Clinic programme, based on PACK and APC, aiming to integrate and strengthen chronic disease management in all 3500 primary care clinics in the country. These clinics are the main source of health care for 50 million South Africans without health insurance. Evidence that a clinic uses PACK or APC is an Ideal Clinic audit standard [5.2]. Four South African nursing schools and three medical schools added PACK to their undergraduate curricula since 2014 [5.1].

4.2 PACK extended to Brazil, Nigeria and Ethiopia

KTU adapted PACK for international dissemination. PACK Global Adult is the prototype, which is then adapted for each country. KTU updates the guides annually, using the latest evidence about accurate diagnosis and effective treatment (supported by the BMJ Evidence Centre). By 2020, over 185,000 guides had been distributed and 30,000 health workers trained in 6 countries, (including >12,000 trained and 3 new countries involved since 2014) [5.1].

Since 2015, PACK Global Adult has been marketed internationally to government and private providers, in partnership with BMJ Publishing Group. PACK Global Adult is delivered to each country through a comprehensive localisation package which includes: i) PACK Adult Guide (mentoring local partners to adapt content to match local policies and priorities, with annual updating), ii) training (mentoring to adapt training methods), iii) health system strengthening, and iv) monitoring and evaluation [5.4-5.6]. PACK Adult was implemented, through training and dissemination of materials, in 52 clinics in 3 Nigerian states from 2016 to 2018, with World Bank funding [5.4]. In 2018 PACK Adult was adapted for Ethiopia, and 100 master trainers from the Ethiopian Ministry of Health were trained; they are currently training frontline primary care workers in every primary care facility in all 9 regions of the country [5.5]. PACK Adult was first rolled out as a randomised controlled trial in the Brazilian city of Florianopolis in 2016, and in 2018 was extended to cover the whole city of 480,000 residents [5.6, 5.7]. Expansion of PACK Adult Brazil to all of Brazil is currently being negotiated, although disrupted by COVID-19.

Using PACK Adult principles, PACK Child guidelines and materials were written, training was piloted and optimised in South Africa from 2017-2019, and planning for province- and nationwide implementation are under way. PACK Adolescent guidelines have been written, and piloting of training begins in 2021. Using this experience, Bachmann is also working with UK and East African researchers, and health ministries, on a randomised trial and upscaling of integrated primary care for HIV, diabetes and hypertension in Uganda and Tanzania, which began in 2020. Impact from this research is expected after 2020.

4.3 Further expansion of antiretroviral treatment in South Africa

Continuing the impact of the 2010 STRETCH trial of nurse initiation and monitoring of antiretroviral treatment (ART) [2.3], ART continues to expand in South African, reaching 5.2 million people by 2019, with over 1.9 million having started ART since 2014 [5.8].

4.4 Health impact

The health impact of these programmes on African and Brazilian populations is likely to be huge. Independent research has shown that implementation of Primary Care 101 guidelines in South Africa would reduce the burden of cardiovascular disease and diabetes by 7.5 disability adjusted life years (DALYs) per 1000 population per year and would save USD24,902 per DALY gained [5.3].

Almost everyone currently receiving ART in South Africa would eventually die of AIDS without it. Our cohort study (Fairall LR, Bachmann MO, Louwagie G, et al, 2007), completed before and justifying the STRETCH trial, used data from a province-wide government HIV programme and rigorous causal modelling, to estimate that ART reduced the risk of death by 86%. This means that >4.4 million lives would be saved (85% of 5.2 million), including >1.6 million who started ART since 2014 (85% of 1.9 million). Tuberculosis incidence in South Africa decreased by about 177,000 cases per year from 2014 to 2019 [5.9], primarily due to ART expansion.