Leaving no one behind: lessons from implementation of policies for universal HIV treatment to universal health coverage

Abstract

Background: The third Sustainable Development Goal (SDG − 3) aims to ensure healthy lives and promote wellbeing for all at all ages. SDG-3 has a specific target on universal health coverage (UHC), which emphasizes the importance of all people and communities having access to quality health services without risking financial hardship. The objective of this study is to review progress towards UHC using antiretroviral treatment (ART) as a case study. Methods: We used a mixed-methods design including qualitative and quantitative approaches. We reviewed and synthesised the evidence on the evolution of the WHO HIV treatment guidelines between 2002 and 2019. We calculated ART coverage over time by gender, age group, and location. We also estimated ART coverage differences and ratios. Findings: ART guidelines have evolved from "treating the sickest" to "treating all". ART coverage increased globally from under 7% in 2005 to 62% in 2018. There have been successes in increasing ART coverage in all populations and locations. However, progress varies by population and location in many regions. There is inequity in ART coverage: women (68%) versus men (55%), and adults (62%) versus children (54%). This inequity has widened over time, and with expanded ART eligibility criteria. On the other hand, data from at least one high-burden country (Ethiopia) shows that inequity among regions has narrowed over time due to the improvements in the primary health care systems and implementation of the public health approach in the country. Conclusion: ART coverage has increased at global, regional and national levels to all population groups. However, the gains have not been equitable among locations and populations. Policies towards universality may widen the inequity in resource-limited settings unless countries take precautions and "put the last first". We argue that primary health care and public health approaches, with multi-sectoral actions and community engagement, are vital to minimize inequity, achieve UHC and leave no one behind.

Intersectional (in) equities in contact coverage of maternal and newborn health services in Nepal: insights from a nationwide cross-sectional household survey

“…The study indicates that despite policies and programs in Nepal aimed at improving MNH, including the safe delivery incentive program (SDIP) and the free health care program, affirmative action to disadvantaged women is needed to reduce persistent inequities in contact coverage [51]. Continuing to implement programs using a one-size-fits-all approach, is likely to increase access to services, rather than decrease equity gaps among women with social disadvantages [52][53][54]. Available evidence suggests when policies and programs are designed and implemented using a universal approach, people within the higher socioeconomic strata of society receive services first compared to disadvantaged women.…”

How does HIV testing modality impact the cascade of care among persons diagnosed with HIV in Ethiopia?

“…Finding new strategies to increase access to testing, especially for populations that are not adequately reached by traditional test modalities, is therefore a priority for HIV programmes. Decentralization and community engagement are recognized as key components for achieving high HIV care coverage in areas with successful rollout of testing and treatment services [ 18 ]. Community-based testing has been shown to increase uptake of testing [ 3 ], but it is uncertain how type of test modality affects the subsequent cascade of HIV care.…”

Social Inclusion and Immunisation

“…WHO antiretroviral therapy (ART) guidelines have evolved from "treating the sickest" to "treating all" (Assefa et al, 2020). This has achieved successes in increasing ART coverage in all populations and locations.…”

“…This has achieved successes in increasing ART coverage in all populations and locations. However, global data has shown inequity in ART coverage: women (68%) versus men (55%), and adults (62%) versus children (54%) (Assefa et al, 2020). This inequity has widened over time, and with expanded ART eligibility criteria.…”