Lack of attention to these interpersonal and social dynamics limits understanding of how they can be intervened upon to support and scale-up the programme.
intimate sexual relationships and between mother and child), and management of treatment requiring a lifelong relationship with the health service. These dynamics matter for programme scale-up as HIV is a distinctly social disease, with transmission taking place in the most intimate aspects of human life (e.g. The disproportionate underrepresentation of interpersonal and social dynamics in expanding ART access in South Africa mirrors their perceived importance in the country’s epidemic response. This indicates that research on this subject is skewed towards understanding expanded ART access in South Africa in terms of individual-level factors that impact engagements along the HIV care continuum (such as age, gender, CD4 count and key population groups) and health systems infrastructure challenges (such as task shifting, staff shortages and the need for innovative models of care). The 194 research articles identified in this scoping review of the challenges and opportunities of expanded antiretroviral treatment (ART) access in South Africa predominantly reported on individual-level and health systems infrastructure factors. An overwhelming focus on individual and health systems infrastructure factors in the published literature on expanded ART access in South Africa may skew understanding of HIV programme shortfalls away from the relational aspects of HIV services delivery and delay progress with finding ways to leverage non-medical modalities for achieving HIV epidemic control. Unlike the published literature, the consultative process offered particular insights into the importance of researching and intervening in the relational aspects of HIV service delivery as South Africa’s HIV programme expands. We contextualized our findings through a consultative process with a group of researchers, HIV clinicians and programme managers to consider critical knowledge gaps. The peer-reviewed literature focused on the individual and health systems infrastructure opinion pieces focused on changing roles of individuals, communities and health services implementers. We included 194 research articles and 23 opinion pieces, of 1512 identified, addressing expanded ART access in South Africa. We used an adapted socio-ecological thematic framework to categorize data according to where it located the challenges and opportunities of expanded ART eligibility: individual/client, health worker–client relationship, clinic/community context, health systems infrastructure and/or policy context. Data collection included systematic searches of two databases and hand-searching of a sub-sample of reference lists. To do so, we adapted Arksey and O’Malley’s six-stage scoping review framework to describe the peer-reviewed literature and opinion pieces on expanding access to ART in South Africa between 20. Using South Africa as a case example, we describe the research priorities and foci in the literature on expanded ART access. ‘Universal’ access to antiretroviral treatment (ART) has become the global standard for treating people living with HIV and achieving epidemic control yet, findings from numerous ‘test and treat’ trials and implementation studies in sub-Saharan Africa suggest that bringing ‘universal' access to ART to scale is more complex than anticipated.
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