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In March 2020, the Anova Health Institute Accelerating Program Achievements to Control the Epidemic (ANOVA\\APACE) program in City of Johannesburg, approached the University of the Witwatersrand (WITS) with the view to enrol medical students in a COVID-19 disaster management volunteer initiative. The aim of the initiative was to provide Masters and PHD students from the WITS medical faculty and Anova interns an opportunity to acquire first-hand experience of managing an epidemic at health facility level. They were also tasked with assisting various clinics to prepare for the expected spike in Coronavirus (COVID-19) cases. A total of 10 students responded to the call and provided to volunteer at 13 clinics over a period of 2 months. At program commencement, the students were provided comprehensive training on COVID-19. The training was to teach them about the virus, as well as prevention and protection measures. Once they were well orientated, they assisted the clinics to manage the flow of patients and step into the role of foot soldiers, as well as close and capture filing gaps. During the second week, they started with the action deliverables of COVID-19 preparedness which entailed painting zones, setting up seating areas, and stationing sanitizers at key traffic points. “I have to say it\’s been a fun and educational journey and thank you for giving me the opportunity to help health facilities maintain and reduce the spread of COVID-19. It really makes me feel proud to know that I am playing a part in helping the communities and health workers during this outbreak.” Said Mosa Tladi, WITS student volunteer. Training on disaster preparedness is critical for medical students. According to Dr Wayne Smith, Head of Disaster Medicine and Special Events at the Western Cape Department of Health: “The management of the medical effects of major incidents and disasters is one of the most difficult tasks to be performed by medical practitioners. The incidents of such events are increasing worldwide, and medical staff are often at the forefront of dealing with the effects.” Concludes Dr Smith. The students were encouraged to contribute and support clinic staff at a professional level too. They participated in ‘clinic rounds’ with the facility managers and learnt how facilities were grouped into clusters and the effort required to coordinate teams daily. In addition, the support the students provided was critical as clinics which were overwhelmed by the reorganizing and preparation that they were undergoing in order to adequately respond to COVID-19 infections. With support from PEPFAR, through the US Agency for International Development (USAID), the ANOVA\\APACE activity aims to control the HIV epidemic in Gauteng, Limpopo, and Western Cape. ANOVA\\APACE works with the Department of Health (DoH) to provide technical assistance that enhances capacity in the HIV and TB continuum of care and the strengthening of the health system. Although not the focus of the ANOVA\\APACE program, the program’s involvement in the response to COVID-19 is critical. Also, HIV and COVID-19 are integrally related as people with pre-existing conditions appear to be more vulnerable to becoming severely ill with the virus. “I am thankful for the opportunity to familiarize myself with the South African health system. From the discussions and conversations, I could sense the unquestionable willingness to be part of Anova, an organization that strives towards improving implementation processes and practices, which seem to be the major barrier towards achieving optimal health outcomes.” Said Jane Scotch, WITS student volunteer. ANOVA \\APACE saw great value in investing in this initiative in order to empower future generations to better prepare for and manage disasters, with a view to assist the health system to become more agile. “The contribution of the students towards the COVID-19 preparedness was a great act of solidarity, especially since Mandela Day is around the corner. The students have shown a huge amount of dedication and we want to celebrate them for their efforts and the example they have set for others.”  Said Dr Bongile Mabilane, Cluster Programme Manager Anova Health Institute. Anova/APACE Program The Anova Health Institute was awarded a PEPFAR grant in 2018 through USAID’s APACE activity (Accelerating Program Achievements to Control the Epidemic). ANOVA\\APACE is aligned with PEPFAR’s aim to support South Africa’s National Strategic Plan for HIV and TB and the UNAIDS 90-90-90 goals to end AIDS. The ANOVA\\APACE Program aims to accelerate and sustain epidemic control in the target districts through a data-driven, people-centred and evidence-informed approach.  

Bokang Molepo, a 21-year-old woman from Mopani, was diagnosed with HIV at 9 years old and was immediately put onto antiretroviral treatment (ART).  

After the death of her mother, Ndivuwo who is 5 years old and her two siblings have been staying with their Grandparents residing in Giyani. The family stays quite a distance away from the nearest clinic and, due to financial constraints, were unable to travel to the health facility for regular check-ups for 20 months. As a result, Ndivuwo’s health deteriorated because she had no access to the treatment she required. Ndivuwo was diagnosed with HIV in September of 2014. In March 2019, Anova Health Institute Accelerating Program Achievements to Control the Epidemic (ANOVA/APACE) program health workers saw the family at Makhuva clinic. The health workers found that Ndivuwo’s situation had worsened since her last clinic visit in July 2017. She had developed septic sores all over her head, and her viral load was not suppressed.  Her siblings also required medical attention as they had developed sores all over their bodies too. The Anova health workers assisted Ndivuwo and her siblings to get the required medical attention and the appropriate medication. Anova health workers also visited their home, with a view to further understand their situation and assist with the appropriate interventions. They discovered that Ndivuwo and her family are facing even more challenges. The grandparents are unemployed, very poor and do not have money for necessities such as food, clothes, and transport. Their house was also in a dilapidated state. Anova contacted the Department of Social Development and the Mayor of Greater Giyani, Cllr Basani Agnes Shibambu to intervene. Anova Health staff at the Giyani subdistrict office were so moved by the situation and donated personal funds towards groceries and the installation of a door for the family home. Ndivuwo and her sibling’s health conditions have greatly improved since Anova’s intervention. The sceptic sores that had developed on her head have healed as a result of her getting access to the medication she required. “Thank you for helping me. I felt good about what Anova did. The assistance with the children’s medical issues was good and when the sores come back, we can keep going back for further assistance.” Said Ndivuwo’s grandmother. The Department of Social Development and the Mayor has also since intervened and have visited Ndivuwo and her family. They are currently exploring the options for better living conditions for the family and have assisted with food parcels, school uniforms and counselling. With support from PEPFAR, through the US Agency for International Development (USAID), the ANOVA\\APACE activity aims to control the HIV epidemic in Gauteng, Limpopo, and Western Cape. ANOVA\\APACE works with the Department of Health (DoH) to provide technical assistance that enhances capacity in the HIV and TB continuum of care and the strengthening of the health systems. Through this work, Anova has also developed a partnership with the Department of Social Development (DSD) in order to jointly tackle the issues of poverty and poor health which are intrinsically linked. “The Department of Social Development in Mopani has a good relationship with Anova. We work together to assist vulnerable people in the communities.” Said Yvonne Chauke, District Social Worker from the DSD. ANOVA\\APACE will continue to collaborate, where possible, with DSD to assist vulnerable and underserved communities. These communities are often deprived of the information, finances or access to the health services they need for the prevention and treatment of diseases. Going forward, this partnership is a major link towards strengthening the health systems of South Africa. Some names and identifying details have been changed to protect the privacy of individuals.

Minister of Basic Education Angie Motshekga recently announced that schools will be opening for grade 7 and 12 learners as of 1 June 2020. South Africa has seen a jump in numbers in the past few weeks, at the time this article was published, SA’s numbers were sitting at just over 19 000 with infected cases. Our country does however have one of the lowest death rates. While many parents agree and can\’t wait for school to open fully, others are saying that it\’s too risky to return to school soon. But the minister has assured parents that necessary precautions will take place in schools to ensure the safety of students. “It is managed by people that are trained, they screen, they check the temperature. We have linked every school to a clinic, if you find a child with a high temperature, we will handle it the way it is handled everywhere else. We have community health workers who will be screening at the gate.” Said Motshekga at a press conference when asked about how schools would screen their students for any potential COVID-19 symptoms “There are three principles guiding us – making sure that schools don’t become centres where the virus can be spread, making sure children don’t get infected in schools but also enabling them to continue with what is rightfully theirs, the right to education and the right to be taken care of.” Concluded the minister. As a parent, there’s not much you can do at making sure your child adheres to the school rules while at school, but here are some measures (provided by https://www.cdc.gov/) you can take to help protect your kids while at home. Clean hands often using soap and water or alcohol-based hand sanitizer. Children 2 years and older should wear a cloth face covering over their nose and mouth when in public settings where it’s difficult to practice social distancing. Clean and disinfect high-touch surfaces daily in household common areas (like tables, hard-backed chairs, doorknobs, light switches, remotes, handles, desks, toilets, and sinks). Limit time with other children outside school. If children meet in groups, it can put everyone at risk. Children can pass this virus onto others who may be at higher risk. Practice social distancing. The key to slowing the spread of COVID-19 is to limit contact as much as possible. While school is out, children should not have in-person playdates with children from other households. If children are playing outside their own homes, it is essential that they remain 6 feet from anyone who is not in their own household. Visit https://www.cdc.gov/ for more updates and tips.

Abstract Same-day initiation (SDI) of antiretroviral therapy (ART) has been recommended to improve ART programme outcomes in South Africa since August 2017. This study assessed implementation of SDI over time in two South African districts, describing the characteristics of same-day initiators and evaluating the impact of SDI on retention in ART care. Routine data were analysed for HIV-infected adults who were newly initiating ART in Johannesburg or Mopani Districts between October 2017 and June 2018. Characteristics of same-day ART initiators were compared to later initiators, and losses to follow-up (LTFU) to six months were assessed using Kaplan Meier survival analysis and multivariate logistic regression. The dataset comprised 32 290 records (29 964 from Johannesburg and 2 326 from Mopani). The overall rate of SDI was 40.4% (n = 13 038), increasing from 30.3% in October 2017 to 54.2% in June 2018. Same-day ART initiators were younger, more likely to be female and presented with less advanced clinical disease than those initiating treatment at later times following diagnosis (p<0.001 for all). SDI was associated with disengagement from care: LTFU was 30.1% in the SDI group compared to 22.4%, 19.8% and 21.9% among clients initiating ART 1–7 days, 8–21 days and ≥22 days after HIV diagnosis, respectively (p<0.001). LTFU was significantly more likely among clients in Johannesburg versus Mopani (adjusted odds ratio (aOR) = 1.43, p<0.001) and among same-day versus later initiators (aOR = 1.45, p<0.001), while increasing age reduced LTFU (aOR = 0.97, p<0.001). In conclusion, SDI has increased over time as per national guidelines, but there is serious concern regarding the reduced rate of retention among same-day initiators. Nevertheless, SDI may result in a net programmatic benefit provided that interventions are implemented to support client readiness for treatment and ongoing engagement in ART care, particularly among younger adults in large ART programmes such as Johannesburg. Introduction South Africa’s antiretroviral therapy (ART) programme for the treatment of human immunodeficiency virus (HIV) infection was launched in 2004. At the time, 4.1 million adults over the age of 15 years were living with HIV and within a decade, an additional 2.2 million adults were infected with the virus [1]. National ART guidelines evolved over this time to treat increasing numbers of HIV-infected clients and to provide improved care and treatment services. South Africa’s ART programme has since grown to be the largest world-wide, with an estimated 4.2 million adults receiving ART in 2017 [2]. When South Africa’s ART programme first started, adults with CD4 counts <200 cells/mm3 were eligible to initiate treatment [3]. The CD4 cut-off was raised to 350 cells/mm3 in August 2011 [4] and to 500 cells/mm3 from January 2015 [5]. However, despite the expanding ART eligibility criteria, South Africa faced challenges in reaching the second 90-90-90 target, namely the provision of ART to 90% of HIV diagnosed individuals, with only 56.9% of HIV-diagnosed adults receiving ART nationally by the middle of 2015 [6]. In September 2016 the National Department of Health (NDoH) implemented universal test and treat (UTT) whereby all adults became eligible to initiate ART irrespective of CD4 count [7], but adult ART coverage increased only minimally to 61% in 2017 [2]. This is consistent with findings from a South African study regarding the significantly decreased likelihood of ART initiation with increasing baseline CD4 count [8], as clients feel “too healthy” to initiate treatment [9]. In addition, numerous other barriers to ART initiation may have impacted treatment coverage rates, including distance to testing centres, transport costs, over-busy clinics and the need for repeat facility visits at the time ART eligibility was being assessed [10, 11]. In order to address ongoing challenges with ART initiation, the NDoH implemented same-day initiation (SDI), namely ART initiation on the same day as HIV diagnosis [12]. The NDoH circular signed in August 2017 requested all public health facilities to scale up ART initiation for all HIV-infected individuals as per UTT guidelines, with an emphasis on providing SDI for individuals newly diagnosed with HIV who were clinically and psychologically ready for lifelong ART [12]. Clinical readiness encompasses screening for symptoms of tuberculosis (TB) and cryptococcal meningitis, as initiation of ART must be delayed in clients with these conditions in order to avoid complications such as immune reconstitution inflammatory syndrome [13]. When appropriately implemented, SDI has the potential to prevent the loss of ART-eligible clients from pre-ART care prior to treatment initiation, a challenge that has been described in multiple sub-Saharan African settings, including South Africa [14, 15]. A number of randomised trials of rapid ART initiation have indeed demonstrated multiple benefits of rapid initiation compared to later ART start, including improved ART uptake by 3 months, increased retention in care at 12 months, higher rates of 12-month viral suppression and reduced risk of mortality [16–19]. However, randomised trials precisely control the environment in which the intervention is being assessed, and it therefore cannot be automatically assumed that findings from these trials regarding the benefits of SDI would translate into routine settings [20]. Although a number of observational studies of SDI in sub-Saharan African settings have also been performed, these studies focussed on pregnant and breastfeeding women and the results may therefore not be generalizable to the wider adult population [21–24]. Other routine studies have been limited to hospitals [25] or have described SDI in the context of specialised interventions such as peer-delivered linkage case management or a revised ART initiation counselling model implemented at a single facility [26, 27]. There is thus a paucity of data regarding the implementation of a national policy for SDI across the whole adult population in routine sub-Saharan African settings. In order to fill this gap, this study aimed to analyse routine programme data to assess implementation of SDI over time and its impact on programme outcomes in an urban and rural district of South Africa. Specifically, this study aimed to compare characteristics of clients who initiate ART on the same day as HIV diagnosis to clients who initiate treatment at later time points after diagnosis, and to assess