Health systems strengthening
HIV testing, care, and treatment


Johns Hopkins University
Aurum Institute




Ekurhuleni District, South Africa


Christopher Hoffmann, Johns Hopkins University
Tonderai Mabuto, Aurum Institute

A Systems Approach to Improving Delivery and Uptake of Facility-based HIV Testing and Linkage to Care in South Africa

The issue
Health facility-based HIV testing services (HTS) is a longstanding and important method for identifying individuals living with HIV. Compared to those diagnosed outside of a health facility, men and women who receive their HIV diagnosis at a clinic or hospital are more likely to continue into care. Unfortunately, facility-based HTS remains underutilized in South Africa—even in the context of opt-out testing. Additionally, even when people living with HIV are diagnosed, linkages to care (LTC) are often not made in a timely manner, limiting access to antiretroviral treatment and the possibilities of viral suppression.


Our approach
Project SOAR is examining the current delivery of HTS and LTC services—including barriers, facilitators, and infrastructure—in Ekurhuleni District, which has the second-highest district-level HIV prevalence (14.3 percent) in the country. This formative research study consists of five activities: (1) valley stream mapping to document the time and inputs required for patients in each of the care settings to go through the HTS and LTC processes; (2) client exit interviews to determine their uptake of HTS; (3) staff and patient in-depth interviews to gain a richer understanding of the barriers to and opportunities for HTS from different perspectives; (4) counseling message assessment through audio-recording of post-test counseling sessions; and (5) facility assessment to characterize the staffing, space, and patient flow at each facility.


The impact
Understanding the dynamics of HTS across different types of health facilities and clinical settings and the key constraints to its optimal delivery will provide needed information for optimizing the role of facility-based HTS as a critical public health tool in South Africa and elsewhere.