Academic journal article Bulletin of the World Health Organization

A Comparative Analysis of National HIV Policies in Six African Countries with Generalized epidemics/Analyse Comparative Des Politiques Nationals De Lutte Contre le VIH Dans Six Pays Africains Ou L'epidemie Est generalisee/Un Analyses Comparativo De Las Politicas Sobre El VIH En Seis Paises Africanos Con Epidemias Generalizadas

Academic journal article Bulletin of the World Health Organization

A Comparative Analysis of National HIV Policies in Six African Countries with Generalized epidemics/Analyse Comparative Des Politiques Nationals De Lutte Contre le VIH Dans Six Pays Africains Ou L'epidemie Est generalisee/Un Analyses Comparativo De Las Politicas Sobre El VIH En Seis Paises Africanos Con Epidemias Generalizadas

Article excerpt

Introduction

By the end of 2012, more than 7.5 million of the estimated 23.5 million people living with human immunodeficiency virus (HIV) in Africa were receiving treatment, compared to only 50 000 people a decade before. (1) The scale-up of treatment services in such a short period of time has been remarkable. Recent evidence suggests that HIV-attributable mortality has declined by more than 50% since antiretroviral therapy (ART) became available. (2-8)

Nonetheless, considerable concerns remain regarding high attrition rates throughout the continuum of care from HIV diagnosis, pre-ART care, timely initiation of ART and long-term retention in treatment. (9) Various studies have observed substantial drop-out of people living with HIV across this care cascade. A recent pooled analysis of 37 studies in sub-Saharan Africa indicates that among those knowing their status, only 57% completed ART eligibility assessment, 66% of those eligible initiated ART and 65% of those initiating treatment were retained on ART. (10)

The network for analysing longitudinal population-based data on HIV in Africa (ALPHA) is investigating the extent of declines in HIV-related adult mortality attributable to treatment and the distribution of deaths at each stage of the diagnosis-to-treatment cascade. (11-14) The network collects community-based data from 10 health and demographic surveillance sites in six countries with generalized epidemics--Kenya, Malawi, South Africa, Uganda, the United Republic of Tanzania and Zimbabwe. Table 1 identifies the ALPHA network sites and provides contextual information on the epidemic and treatment programme in each country.

To interpret site- and country-specific differences in mortality rates across the diagnosis-to-treatment cascade, we analysed national HIV policies. It is helpful for the agencies that define programme priorities and analyse differences in outcomes to understand the incentives and barriers to accessing --and remaining on--ART in different contexts. Our analysis focuses on the policy response to the HIV epidemic. We have not investigated the sociocultural barriers within communities that influence access to services in different sites.

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Methods

A conceptual framework was developed, identifying key HIV policy and programmatic factors that may influence HIV-related adult mortality (Fig. 1). These factors were derived from a review of the literature (including a recent systematic review on health sector interventions to ensure a continuum of care), (10) an initial review of World Health Organization (WHO) guidelines and expert review of indicators by 28 HIV researchers and clinicians. Through the literature review and preliminary analysis of ALPHA network mortality data, we identified three attrition points to inform the structure of our policy review: (i) access to HIV testing and counselling; (ii) access to HIV care and treatment (including assessment of eligibility for treatment initiation and initiation itself); and (iii) retention on ART. Across these three attrition points (diagnosis, HIV care and retention), relevant factors fell into the following five areas: (i) service access and coverage; (ii) quality of care; (iii) coordination of care and patient tracking; (iv) medical management; and (v) support to people living with HIV.

A policy extraction tool was developed to facilitate the indicator review (available from the author). Documents were searched online through ministry of health and national HIV organization websites and/or retrieved in person from official offices and libraries, using the following inclusion criteria: (i) nationally relevant (not clinic- or district-specific); (ii) containing programmatic or clinical guidance on one of the three key adult HIV services: HIV testing and counselling, prevention of mother-to-child transmission (PMTCT) or HIV care and treatment; (iii) published between January 2003 and June 2013. …

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