Background Herpes simplex virus type 2 (HSV-2) is the leading cause of genital ulcer disease (GUD) worldwide. Treatment with acyclovir has been shown to shorten GUD duration, decrease plasma and genital HIV RNA levels and slow HIV disease progression in several trials. In South Africa, STI management guidelines were revised in 2008 to include acyclovir as first-line GUD therapy. However, acyclovir access appeared to be unequal across various settings. This study attempted to understand acyclovir access in South Africa from both a supply and demand perspective.
Methods The study was cross-sectional and primarily qualitative. Three groups of participants were recruited to reflect acyclovir access and use: policymaker key informants, healthcare providers at public primary healthcare facilities and ART initiation sites in greater Johannesburg, and former HSV-2 treatment trial participants (both genders, HIV-positive and -negative). Information was collected following the WHO/Health Action International two-stage cluster random selection of health units through standardised questionnaires, complemented by in-depth interviews with selected stakeholders.
Results Acyclovir was documented to be widely available. Challenges to access included the initial policy development and implementation process, staff training, accessibility and availability. The updated guidelines appeared to have been introduced with little high-level co-ordination and minimal staff training, although policymakers and staff thought that HSV-2 treatment was both efficacious and useful. Clinics did not experience drug stock outs. The demand for acyclovir appeared to be poor and influenced by limited knowledge of HSV-2 by the general public, negative perceptions associated with HSV-2 infection, adverse logistical factors like long waiting times at clinics and negative experiences with staff at clinics.
Conclusions The South African guidelines were supported by local research evidence in line with WHO recommendations. Although little attention was paid to how the new guidelines had to be introduced, implemented and monitored, both the supply and prescribers' awareness improved rapidly. Access to acyclovir was undermined by poor demand from patients. Individuals possibly did not see herpes as enough of a problem to seek treatment. To ensure the success of new treatment approaches, it is essential to consider user and well as provider issues.