Tove Sørensen
Norwegian Centre for Telemedicine, Tromso, Norway

Ulrike Rivett
Cell-Life, Cape Town, South Africa

Jill Fortuin
Medical Research Council, Cape Town, South Africa

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Introduction

HIV/AIDS is a major global health problem. In South Africa, it is estimated that 5.4 million people are infected by HIV, out of a population of nearly 48 million, giving a prevalence rate of about 11%. About 600,000 individuals are infected with AIDS. Furthermore, the estimates show that, by mid-2006, some 711,000 people were in need of anti-retroviral treatment (ART), while 225,000 were actually receiving it.[1]

HIV/AIDS treatment and management strategies require ongoing monitoring and evaluation, and telemedicine and e-health systems have been recommended as a supporting tool.[2][3] One of the challenges for access to treatment through anti-retroviral medication is the difficulty of receiving accurate and up-to-date information at the planning level.[1] Information and communication technology (ICT) has been used in a number of pilot studies to address this bottleneck, by providing an infrastructure for telemedicine and e-health applications.[4][5] These projects suggest that the ART delivery to poor communities can be significantly improved by integrating local primary health-care information with centralized databases to allow national monitoring.

So far, little evidence has been documented on the use of ICT for mitigating HIV/AIDS6 in South Africa and elsewhere, with a few exceptions.[3][7-9] To our knowledge, there is no baseline study on telemedicine, e-health or e-readiness for South Africa. There is no agency, private nor public, which offers an overview of e-health and telemedicine projects and systems in South Africa. The WHO 'Global e-health observatory' has so far no information on South Africa.[10] However, a Presidential National Commission on Information Society and Development has been established, with a section on e-health. The mandate states that it will investigate the use of e-health in the country.[11]

The aim of the present study was to provide an overview of telemedicine and e-health systems for HIV/AIDS in South Africa as a basis for developing an 'e-health toolkit' for ART.

Methods

The study was conducted from September to December of 2006. An initial literature review and a subsequent interactive networking approach were chosen to identify telemedicine and e-health systems, projects and services for HIV/AIDS and ART-facilities in low-resource settings and under-served areas.

A total of three scientific databases were searched, namely Pubmed/Medline, Science Direct and Biblioline. The searches were limited to articles published between 2002 and 2005, inclusive. Queries were made for telemedicine and e-health studies conducted in South Africa. Additional criteria were that studies were reported in the English language and that they were studies on human subjects.

We used the following search words: 'ART', 'ARV', ('Anti-Retroviral' and 'HAART'), 'HIV', 'AIDS' and 'ICT', 'e-health' (eHealth), 'tele-health', 'telemedicine', 'cell-phone' (cell phone), 'mobile' (application), 'Internet', 'web'. Searches were also made for 'needs-assessment' and 'review' in order to check for similar studies.

A systematic web search was conducted in a similar manner. This entailed searching specific websites that were likely to have the desired information, e.g. funding agencies, government and research,[12] as well as general web searches using Google and the search words as listed above. A database with 1615 papers collected for a review study on methods of telemedicine and e-health literature (1990- 2005) was searched.[13] The last search was performed in November 2006.

Since very little information was found with these search strategies, each province was contacted via email and asked if they could assist with information on ICT-related systems or projects in their province. Project managers, health-care professionals, and telemedicine and e-health stakeholders were contacted by telephone and in face-to-face meetings. The preliminary findings of the review and interviews were presented and revised after discussions with a group of researchers and other stakeholders.

Results

The literature review returned few publications on the topic. The majority of articles described projects about information on HIV/AIDS.[14-16] Only a few papers described clinical systems and direct patient communication,[17][18] such as Health Electronic Records in Haiti.[19][20] One of the few papers from Africa concerned electronic health records focusing on HIV/AIDS in Kenya.[21] The study 'Health toolkit' was the only study found which assessed ICT systems for health.[22] It focused on NGOs working with HIV/AIDS in various countries. Of the 17 products assessed, none was considered immediately deployable in the target settings.[22] No published scientific papers from South Africa were found, nor were technical reports or relevant information readily available.

The web searches returned several hits from South Africa, which were mainly conference abstracts and presentations.[23-29] Most of the information was collected through meetings and conferences with stakeholders. No reports of needs assessment and technology readiness were published within this specific field, but a few in-housepapers were uncovered through communication with project managers, telemedicine and e-health stakeholders. Table 1 gives an overview of the results grouped into the following categories: Health information systems (HIS), Electronic health records (EHR), Pharmacy management systems, Laboratory systems, Remote diagnostics (telemedicine consultations), Home-based care and direct patient communication, and Blended learning. There were far more ICT systems on information handling (HIS and EHR) than on direct patient consultations (Table 1).

Type of ICT System	Examples	Comments
Health Information (Management) System	Paper-Based National Reporting System (for ART): Medicom and Paab modules are based on these requirements[33] PEPFAR-Reporting System and Other NGO Systems[31] Home Affairs National Identification System (smart card, reduced EHR)[34]	There are health information systems at provincial and national level The private health, mining and military sectors each have their own systems
Electronic Health Records	Open MRS[32] Electronic Medical Records[35] Electronic Health Record, South Africa[36] Smart-Card[37]	Two main types: with clinical data (identifiable) and for research only (non- identifiable) Various storage devices, (smart-card, database, web)
Pharmacy Management System	Medicom HIS - HIV/AIDS Component[33] ComputerKit Systems - Unisolv[38] Mediware - JAC Stock Control and Drug Accounting System[39] iDART[40] PharmASSIST[41]	Some of the systems are commercial and some are NGO-based like iDART
Laboratory System	TOGA Laboratory System (Microsoft based)[25] NHLS Information System[42]	Toga systems are deployed in rural and peri-urban settings in containers. NHLS provides diagnostic laboratory services to a national network of 250 pathology laboratories
Remote Diagnosis (Telemedicine Consultations)	Teledermatology[26] Tele-Ophthalmology[27]	Store-and-forward communication is used to assist rural under-served clinics where there are no specialists available
Home-Based Care and Direct Patient Communication	After-Care: Home-based carriers collect medical and socioeconomic data from AIDS-patients through applications on their mobile phones[43]	SMS reminders have been used for TB AIDS-patients use the alarm clock function in their mobile phones as private reminders to take medication[43]
Blended Learning	Mindset Health Channel[44] Broadcasting health content through radio and TV, e.g. Soul City, Khomanani[45] NEPAD e-Schools health point[46]	The systems target various groups: for the general public, patients and health-care workers
Other	Simpill[47]	'Intelligent' pill-case with reminders for medication

Table 1: Telemedicine and e-health for administering HIV/AIDS in South Africa

No responses were received from the email messages sent to the provinces' health authorities. A strategic plan for the Department of Communication (2005-2008) has been developed which states that it will provide ICT-related support for health.[30] A departmental task team is finalizing an e-strategy, which should have been ready for adoption in 2005.

The legal framework in South Africa provides good procedures for retrieving aggregated health and patient information throughout all government levels. Most of the data reporting thus far has been in paper-based format (particularly from rural clinics to the provincial authorities). The paper-based system (in the form of data points collected at clinic level) is standardized throughout South Africa. The highest aggregated data-set from provincial to the national Department of Health has been delivered in digital format for some time. A number of health information and electronic health record systems have been used at provincial level to standardize reporting. Some of these systems have integrated HIV/AIDS and ART modules to support the primary health-care facilities of the public sector like Medicom, PEPFAR and Open-MRS.[31-33]

Since the findings were limited, we were not able to follow up with the subset of questions we had defined as the aim of the study. None of the systems were ready to deploy on a large scale.

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