Different delivery models for antiretroviral therapy to sub-Saharan Africa in the context of 'Universal Access'

HIV Unit, Ministry of Health, P.O. Box 30377, Lilongwe, Malawi.
Transactions of the Royal Society of Tropical Medicine and Hygiene (Impact Factor: 1.84). 05/2008; 102(4):310-1. DOI: 10.1016/j.trstmh.2008.01.005
Source: PubMed


In 10 years, in line with the concept of universal access, 25 million HIV-infected patients in sub-Saharan Africa might be on antiretroviral therapy (ART). There are different models of ART delivery, from the individualised, medical approach to the simple, public health approach, both having distinct advantages and disadvantages. This mini-review highlights the essential components of both models and argues that, whatever the mix of different models in a country, both must be underpinned by similar core principles so that uninterrupted drug supplies, patient adherence to therapy and compliance with follow up are assured. Failure to do otherwise is to court disaster.

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    • "Think of HAI, World Bank, PEPFAR, GFATM, Sant'Egidio, ASIDH, MSF, UNAIDS, Humana People to People, DANIDA, CARE, HOPE, and many more: one government against ‘1001 actors’ from all corners of the political spectrum. The varying roles of donors, governments and non-state providers, what Palmer calls ‘an awkward threesome’ (Palmer, 2006), influence the emerging mix of ART delivery models in African countries (Harries, Makombe, Schouten, Ben-Smith, & Jahn, 2008). "
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    ABSTRACT: The large-scale introduction of HIV and AIDS services in Mozambique from 2000 onwards occurred in the context of deep political commitment to sovereign nation-building and an important transition in the nation's health system. Simultaneously, the international community encountered a willing state partner that recognised the need to take action against the HIV epidemic. This article examines two critical policy shifts: sustained international funding and public health system integration (the move from parallel to integrated HIV services). The Mozambican government struggles to support its national health system against privatisation, NGO competition and internal brain drain. This is a sovereignty issue. However, the dominant discourse on self-determination shows a contradictory twist: it is part of the political rhetoric to keep the sovereignty discourse alive, while the real challenge is coordination, not partnerships. Nevertheless, we need more anthropological studies to understand the political implications of global health funding and governance. Other studies need to examine the consequences of public health system integration for the quality of access to health care.
    Global Public Health 02/2014; 9(1-2):210-223. DOI:10.1080/17441692.2014.881522 · 0.92 Impact Factor
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    • "Non-adherence is a significant barrier to using antiretroviral therapy (ART) in Africa (Harries et al. 2008). Side effects to treatment; complex drug therapy regimens; patient-related factors such as alcohol abuse and lack of social support; are common barriers to ART adherence in both developed and developing countries (Mills et al. 2006a, Oliveira et al. 2010). "
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    ABSTRACT: Adherence is a decisive factor in achieving a successful response to antiretroviral therapy (ART) for HIV infection. No previous studies have been conducted regarding HIV treatment adherence in Guinea-Bissau. In this study we assessed barriers and facilitators to patient ART adherence. Semi-structured interviews were conducted with 20 adult, HIV infected individuals receiving ART at a HIV treatment centre in Bissau, Guinea-Bissau. The grounded theory method was used to gather and analyse data. Results indicated that HIV-related knowledge was a determining factor for optimal adherence. The facilitators were experienced treatment benefits and complementing social networks. The barriers were treatment-related costs and competing livelihood needs; poor clinic infrastructure; perceived stigma; and traditional practices. Our findings indicate that good ART adherence, especially in resource-limited settings, requires that patients achieve adequate HIV-related knowledge. More studies on HIV-related knowledge and adherence among HIV infected individuals are currently needed.
    African Journal of AIDS Research 03/2013; 12(1):1-8. DOI:10.2989/16085906.2013.815405 · 0.79 Impact Factor
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    • "Scale-up of antiretroviral treatment (ART) began in Malawi in 2004, with initial selection of 60 hospitals across the country to provide broad geographical coverage[2,3]. The Malawi national ART programme follows a public health model focusing on 'service delivery to all who need it'[4]. A generic, fixed-dose combination treatment (Triommune) with stavudine, lamivudine and nevirapine is available as first line treatment and given free of charge to eligible patients. "
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    ABSTRACT: Routine ART programme statistics generally only provide information about individuals who start treatment. We aimed to investigate the outcome of those who are eligible but do not start ART in the Malawi programme, factors associated with this dropout, and reasons for not starting treatment, in a prospective cohort study. Individuals having a first screening visit at the ART clinic at Karonga District Hospital, northern Malawi, between September 2005 and July 2006 were interviewed. Study follow-up to identify treatment outcomes was conducted at the clinic and in the community. Logistic regression models were used to identify factors associated with dropout before ART initiation among participants identified as clinically eligible for ART. 88 participants eligible for ART at their first screening visit (out of 633, 13.9%) defaulted before starting ART. Participants with less education, difficulties in dressing, a more delayed ART initiation appointment, and mid-upper arm circumference (MUAC) < 22 cm were significantly less likely to have visited the clinic subsequently. Thirty-five (58%) of the 60 participants who defaulted and were tracked at home had died, 21 before their ART initiation appointment. MUAC and reported difficulties in dressing may provide useful screening indicators to identify sicker ART-eligible individuals at high risk of dropping out of the programme who might benefit from being brought back quickly or admitted to hospital for observation. Individuals with less education may need adapted health information at screening. Deaths of ART-eligible individuals occurring prior to ART initiation are not included in routine programme statistics. Considering all those who are eligible for ART as a denominator for programme indicators would help to highlight this vulnerable group, in order to identify new opportunities for further improving ART programmes.
    BMC Public Health 10/2010; 10(1):601. DOI:10.1186/1471-2458-10-601 · 2.26 Impact Factor
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