This study aimed to describe the scale-up of a decentralised HIV treatment programme delivered through the primary health care system in rural KwaZulu-Natal, South Africa, and to assess trends in baseline characteristics and outcomes in the study population. A total of 5,719 adults who initiated ART between October 2004 and September 2008 were included and stratified into six-month groups. There was an increase in the proportion of women who initiated ART while pregnant but no change in other baseline characteristics over time. Overall retention in care at 12 months was 84%, while 10.9% died and 3.7% were lost to follow-up. Mortality was highest in the first three months after ART initiation, with 30.1 deaths per 100 person–years. At twelve months, 23% had a detectable viral load. The study concluded that outcomes were not affected by rapid expansion of this decentralised HIV treatment programme. The relatively high rates of detectable viral load highlight the need for further efforts to improve the quality of services.
Equity and HIV/AIDS
"Malawi, Mozambique, Swaziland, and South Africa have some of the highest HIV/AIDS burdens in the world. All four countries have ambitious plans for scaling-up antiretroviral treatment for the millions of HIV-positive people in the region. In January 2004, we visited these countries with the intention of directly observing the effect of AIDS, especially on health systems, to talk with policy makers and field workers about their concerns and perspectives regarding the epidemic, and to investigate the main issues related to scaling up antiretroviral treatment. We found that financial resources are not regarded as the main immediate constraint anymore, but that the lack of human resources for health is deplored as the single most serious obstacle for implementing the national treatment plans."
"We, members of the Pan African Treatment Access Movement (PATAM) who have gathered here in Harare from 3-5 March 2004 to draw up civil society strategies to ensure rapid scale-up of anti-retroviral therapy in Southern Africa understand that everyone in the world is vulnerable to HIV infection and know that HIV-positive people in Africa, particularly women and other vulnerable groups, experience great challenges that must be addressed urgently. We know and understand that there are numerous factors and actors that hamper the provision of affordable life-saving medicines. Some of these include profiteering by pharmaceutical companies, inequitable international trade relationships, poverty, extreme stigma, imbalance of power within patriarchal societies, macroeconomic policies that constrain spending for health care and other social services and a lack of commensurate political commitment by our governments and other leaders to match the scale of the HIV/AIDS pandemic."
Are Uganda’s health systems are being strengthened to sustain access to antiretroviral therapy (ART)? This study applies systems thinking to assess supply chain management, the role of external support and whether investments create the needed synergies to strengthen health systems. The authors combined data from the literature and key informant interviews with observations at health service delivery level in a study district. Findings indicate that current drug supply chain management in Uganda is characterised by parallel processes and information systems that result in poor quality and inefficiencies. Less than expected health system performance, stock outs and other shortages affect ART and primary care in general. Poor performance of supply chain management is amplified by weak conditions at all levels of the health system, including the areas of financing, governance, human resources and information. Governance issues include the lack to follow up initial policy intentions and a focus on narrow, short-term approaches. In conclusion, the study indicates serious missing system prerequisites. The findings suggest that root causes and capacities across the system have to be addressed synergistically to enable systems that can match and accommodate investments in disease-specific interventions. The multiplicity and complexity of existing challenges require a long-term and systems perspective essentially in contrast to the current short term and programme-specific nature of external assistance.
This International Food Policy Research Institute (IPFRI) discussion paper examines the scaling-up of the STEPS initiative (Scaling Up HIV/AIDS Interventions Through Expanded Partnerships) in Malawi, and the factors which interfere with this process. Topics explored in this paper include: Malawi's national response to HIV/AIDS; the pilot project and the development of the community mobilisation model (formerly known as COPE); the scaling up and progress of STEPS; and factors that effect the scaling up process, including the catalysts, institutional arrangements, and organisational capacities. The paper also looks at community-level factors and financing, as well as threats to scaling up, including HIV/AIDS and the ongoing food crisis in the context of widespread and deep poverty, and underdevelopment.
Current anti-retroviral therapy models are doctor-based and labour-intensive, requiring many qualified staff. Yet countries such as Mozambique, Malawi, Zambia, Rwanda and Tanzania lack sufficient skilled health workers to scale up ART according to these models. This paper considers the kind of model needed for effective scale up of ART programmes in countries which lack skilled health workers. They find that ART delivery involves several types of function requiring different approaches. Good organisation of logistics, supplies and distribution calls for a standardised, centrally controlled or bureaucratic approach. However, a more society-based approach is needed when providing community support to patients. The management of patients who do not fit standardised procedures requires a more professional approach. Finally, care of the individual patient requires a combination of the social and professional approaches.
This note, prepared for a UNAIDS workshop on Vulnerability and AIDS, provides a number of observations and opinions on the feasibility of scaling up anti-retroviral treatment (ART) in sub-Saharan Africa. The document reviews lessons learned from various hospitals and health centres delivering ART in southern Africa, and highlights considerable human resource constraints. For instance, in South Africa, it is estimated that for every 500 ART patients, they need as many as 10 permanent staff. Other pilots have similar staff/patient ratios.
The introduction of the South African government's HIV tests on schoolchildren has been delayed by legal and confidentiality concerns, but officials insist a pilot project will start later in the year. After the national Department of Health announced the planned testing in January 2011, a pilot project to test pupils, voluntarily, was due to start at several schools in February. But it was shelved because crucial ethical and legal questions had not been answered. A team was set up to test the feasibility of the project, but four months later it has still not completed its research and consultations. Most teachers' unions and parents' organisations supported the proposal in principle, saying HIV screening could help curb the spread of HIV and reduce teenage pregnancies. But some expressed misgivings about how it might affect pupils and the learning environment. Parents must consent to tests and counselling must be provided by the schools.
The South African government has announced that it will soon launch a controversial step in its national campaign to test 15 million people for HIV by June 2011. Under the plans, children and adolescents will be offered voluntary HIV testing and counselling in high schools. This editorial addresses some of the major obstacles it predicts the campaign will face. Under South African law, children aged 12 years and older can give consent to a HIV test. But some issues remain problematic, such as how a health worker should determine whether consent provided by a 12-year-old or adolescent is sufficiently informed or not, and how to ensure confidentiality of test results. It is also not clear whether children who test positive will receive anti-retroviral therapy, or if parental or peer pressure might be applied on children to divulge their test results. The Lancet editors call on the task team that is planning the intervention to consider whether schools are the best place for children to learn their HIV status. Problems in the national HIV testing and counselling campaign, launched in April 2010, heed a cautionary warning, the editors note. Monitoring and evaluation of the campaign has so far been poor and there have been reports of HIV-positive people not being referred for treatment, clinics not complying with national testing and counselling protocols, and anecdotal reports of coercive testing.
The Scorecard rates countries on their reporting of six key elements in an AIDS response tuned to the needs of women, including the collection of HIV data specific to women; progress in ensuring that women have equal access to HIV services; and the impact of national responses on reducing infections among women and facilitating their access to treatment. The overall score reflects the extent of data provided on each element. Countries with the highest HIV burdens were doing the best job of reporting data detailing their female-centred AIDS efforts, with 67% earning a high rating. However, the authors noted that a high score for reporting did not necessarily reflect good performance in delivering HIV services for women. Relatively good reporting by South Africa, for example, contrasted with a poor record in improving the maternal mortality of HIV-positive women, or curbing high rates of violence against women. There was also a disturbing lack of data on the situation of young girls, and what countries were doing to address their particular vulnerabilities.