A comparative analysis of national HIV policies in six African countries with generalized epidemics

Church, Kathryn; Kiweewa, Francis; Dasgupta, Aisha; Mwangome, Mary; Mpandaguta, Edith; Gómez‐Olivé, Francesc Xavier; Oti, Samuel; Todd, Jim; Wringe, Alison; Geubbels, Eveline; Crampin, Amelia C.; Nakiyingi‐Miiro, Jessica; Hayashi, Chika; Njage, Muthoni; Wagner, Ryan G.; Ario, Alex Riolexus; Makombe, Simon D; Mugurungi, Owen; Żaba, Basia

doi:10.2471/blt.14.147215

Cited by 43 publications

(58 citation statements)

References 16 publications

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“…Malawi often stands out for its progressive HIV policies [10], despite being one of the poorest African countries, and our findings suggest that policies are translating into practice, even in rural areas. Other sites, notably those in Kenya, performed less well across the same indicators, despite having a substantially higher per capita HIV budget and health worker ratios [19].…”

Section: Discussionmentioning

confidence: 78%

Identifying gaps in HIV service delivery across the diagnosis‐to‐treatment cascade: findings from health facility surveys in six sub‐Saharan countries

Church

Machiyama

Todd

et al. 2017

Journal of the International AIDS Society

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Introduction: Despite the rollout of antiretroviral therapy (ART), challenges remain in ensuring timely access to care and treatment for people living with HIV. As part of a multi-country study to investigate HIV mortality, we conducted health facility surveys within 10 health and demographic surveillance system sites across six countries in Eastern and Southern Africa to investigate clinic-level factors influencing (i) use of HIV testing services, (ii) use of HIV care and treatment and (iii) patient retention on ART. Methods: Health facilities (n = 156) were sampled within 10 surveillance sites: Nairobi and Kisumu (Kenya), Karonga (Malawi), Agincourt and uMkhanyakude (South Africa), Ifakara and Kisesa (Tanzania), Kyamulibwa and Rakai (Uganda) and Manicaland (Zimbabwe). Structured questionnaires were administered to in-charge staff members of HIV testing, prevention of mother-to-child transmission (PMTCT) and ART units within the facilities. Forty-one indicators influencing uptake and patient retention along the continuum of HIV care were compared across sites using descriptive statistics. Results: The number of facilities surveyed ranged from six in Malawi to 36 in Zimbabwe. Eighty percent were government-run; 73% were lower-level facilities and 17% were district/referral hospitals. Client load varied widely, from less than one up to 65 HIV testing clients per provider per week. Most facilities (>80%) delivered services or interventions that would support patient retention in care such as delivering free services, offering PMTCT within antenatal care, pre-ART monitoring and adherence counselling. Many facilities under-delivered in several areas, however, such as targeted testing for high-risk groups (21%) and mobile testing (36%). There were also intra-site and inter-site differences, including in the delivery of Option B+ (ranging from 6% in Kisumu to 93% in Kyamulibwa), and nurse-led ART initiation (ranging from 50% in Kisesa to 100% in Karonga and Agincourt). Only facilities in Malawi did not require additional lab tests for ART initiation. Stock-outs of HIV test kits and antiretroviral drugs were particularly common in Tanzania. Conclusions: We identified a high standard of health facility performance in delivering strategies that may support progression through the continuum of HIV care. HIV testing policy and practice was particularly weak. Inter- and intra-country differences in quality and coverage represent opportunities to improve the delivery of comprehensive services to people living with HIV.

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Section: Discussionmentioning

confidence: 78%

Identifying gaps in HIV service delivery across the diagnosis‐to‐treatment cascade: findings from health facility surveys in six sub‐Saharan countries

Church

Machiyama

Todd

et al. 2017

Journal of the International AIDS Society

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“…Results were colour-coded green-orange-red to represent the degree of implementation, and dark or light shading was used to illustrate if policy was explicit or not explicit. Results were grouped into different policy domains, derived from the conceptual framework developed by Church et al: service access and coverage, coordination of patient care and tracking, support to PLHIV, medical management and quality of care [7]. Findings for quality of care are presented separately.…”

Section: Methodsmentioning

confidence: 99%

“…A study by Church et al on behalf of the network for Analysing Longitudinal Population-based HIV data in Africa (ALPHA) reviewed the content of policies relating to HIV testing, treatment and retention in six sub-Saharan African countries (Kenya, Malawi, South Africa, Tanzania, Uganda, Zimbabwe) and found substantial variability in national policy adoption and the extent to which policies adhere to WHO guidelines [7]. While policy reviews are valuable in terms of understanding national-level policy formulation, their translation into practice can often occur incompletely or with unexpected outcomes, and these resulting gaps in care provision may be hypothesised to explain observed health outcomes.…”

Section: Introductionmentioning

confidence: 99%

HIV policy implementation in two health and demographic surveillance sites in Uganda: findings from a national policy review, health facility surveys and key informant interviews

et al. 2017

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BackgroundSuccessful HIV testing, care and treatment policy implementation is essential for realising the reductions in morbidity and mortality those policies are designed to target. While adoption of new HIV policies is rapid, less is known about the facility-level implementation of new policies and the factors influencing this.MethodsWe assessed implementation of national policies about HIV testing, treatment and retention at health facilities serving two health and demographic surveillance sites (HDSS) (10 in Kyamulibwa, 14 in Rakai). Ugandan Ministry of Health HIV policy documents were reviewed in 2013, and pre-determined indicators were extracted relating to the content and nature of guidance on HIV service provision. Facility-level policy implementation was assessed via a structured questionnaire administered to in-charge staff from each health facility. Implementation of policies was classified as wide (≥75% facilities), partial (26–74% facilities) or minimal (≤25% facilities). Semi-structured interviews were conducted with key informants (policy-makers, implementers, researchers) to identify factors influencing implementation; data were analysed using the Framework Method of thematic analysis.ResultsMost policies were widely implemented in both HDSS (free testing, free antiretroviral treatment (ART), WHO first-line regimen as standard, Option B+). Both had notable implementation gaps for policies relating to retention on treatment (availability of nutritional supplements, support groups or isoniazid preventive therapy). Rakai implemented more policies relating to provision of antiretroviral treatment than Kyamulibwa and performed better on quality of care indicators, such as frequency of stock-outs. Factors facilitating implementation were donor investment and support, strong scientific evidence, low policy complexity, phased implementation and effective planning. Limited human resources, infrastructure and health management information systems were perceived as major barriers to effective implementation.ConclusionsMost HIV policies were widely implemented in the two settings; however, gaps in implementation coverage prevail and the value of ensuring complete coverage of existing policies should be considered against the adoption of new policies in regard to resource needs and health benefits.

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“…In addition, at the time this study was implemented, both Kenya and Namibia had national policies supportive of delivering prevention interventions within HIV clinical settings. Factors such as national policies, laws, and cultural norms have been shown to have a strong influence on health behaviors [20] and may help explain some of the observed differences in this study.…”

Section: Discussionmentioning

confidence: 96%

Delivering Prevention Interventions to People Living with HIV in Clinical Care Settings: Results of a Cluster Randomized Trial in Kenya, Namibia, and Tanzania

et al. 2016

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We conducted a group randomized trial to assess the feasibility and effectiveness of a multi-component, clinic-based HIV prevention intervention for HIV-positive patients attending clinical care in Namibia, Kenya, and Tanzania. Eighteen HIV care and treatment clinics (six per country) were randomly assigned to intervention or control arms. Approximately 200 sexually active clients from each clinic were enrolled and interviewed at baseline and 6- and 12-months post-intervention. Mixed model logistic regression with random effects for clinic and participant was used to assess the effectiveness of the intervention. Of 3522 HIV-positive patients enrolled, 3034 (86 %) completed a 12-month follow-up interview. Intervention participants were significantly more likely to report receiving provider-delivered messages on disclosure, partner testing, family planning, alcohol reduction, and consistent condom use compared to participants in comparison clinics. Participants in intervention clinics were less likely to report unprotected sex in the past 2 weeks (OR = 0.56, 95 % CI 0.32, 0.99) compared to participants in comparison clinics. In Tanzania, a higher percentage of participants in intervention clinics (17 %) reported using a highly effective method of contraception compared to participants in comparison clinics (10 %, OR = 2.25, 95 % CI 1.24, 4.10). This effect was not observed in Kenya or Namibia. HIV prevention services are feasible to implement as part of routine care and are associated with a self-reported decrease in unprotected sex. Further operational research is needed to identify strategies to address common operational challenges including staff turnover and large patient volumes.

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A comparative analysis of national HIV policies in six African countries with generalized epidemics

Cited by 43 publications

References 16 publications

Identifying gaps in HIV service delivery across the diagnosis‐to‐treatment cascade: findings from health facility surveys in six sub‐Saharan countries

Identifying gaps in HIV service delivery across the diagnosis‐to‐treatment cascade: findings from health facility surveys in six sub‐Saharan countries

HIV policy implementation in two health and demographic surveillance sites in Uganda: findings from a national policy review, health facility surveys and key informant interviews

Delivering Prevention Interventions to People Living with HIV in Clinical Care Settings: Results of a Cluster Randomized Trial in Kenya, Namibia, and Tanzania

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