Systems Analysis to Increase HIV Testing Delivery and HIV Diagnosis in Primary Care Clinics in South Africa

Background:Provider-initiated testing and counseling remains highly underused in many South African health facilities. We implemented a systems analysis to investigate whether simple adjustments to HIV testing services (HTS) delivery can increase HTS provision.Setting:Ten primary care facilities in the Ekurhuleni District in South Africa.Methods:Following a baseline HTS assessment that showed limited offering of HTS by clinicians, clinic staff had the option to adopt several change approaches to increase HTS delivery using existing human resources. Approaches included adjusting HTS timing, strengthening HTS promotion, counsellor management, and implementing reward systems. Evaluation was conducted identically to the baseline study using patient exit interviews to quantify HTS engagement and value stream mapping to map patient flow through the clinic.Results:We conducted 2163 exit interviews and followed 352 patients for value stream mapping. After change implementation, a significantly higher proportion of patients reported being offered HTS (742/2163, 34.3% vs. 231/2206, 10.5% during the baseline period; χ²P < 0.001) and having undertaken testing (527/2163, 24.4% vs. 197/2206, 8.9% during the baseline period; χ²P < 0.001) with only a 3-percentage point decrease in HIV-positive yield (14.0% vs. 17.1% during the baseline period). The median time to HTS offer decreased from 77 minutes to 3 minutes after clinic arrival during the intervention (χ²P = 0.001).Conclusions:A systems approach can be an effective and appropriate implementation strategy to augment HTS delivery and increase HIV diagnoses. This low-cost approach may be extended to optimize other aspects of clinic service delivery.