[Show abstract][Hide abstract] ABSTRACT: Objectives: To review and summarize the essential components of HIV treatment and care services in low and middle-income countries (LMICs). Methods: Literature review and reflection on programmatic experience. Findings: There is increasing recognition that the essential ‘package’ of HIV care must include early identification of HIV-positive people in need of care, appropriate initial and continued counselling, assessment of HIV disease stage, treatment with HAART for those who need it, monitoring while on treatment for efficacy, adherence and side-effects, detection and management of other complications of HIV infection, provision of sexual and reproductive health services as well as careful record-keeping. The impressive scale-up of HIV treatment and care services has required decentralization of service provision linked to task-shifting. But the future holds even greater challenges, as the number of people in need of HIV care continues to rise at a time when many traditional donors and governments in the most-affected regions have reduced budgets. Conclusion: In the long-term, the increased demand for HIV-care services can only be satisfied through increased decentralisation to peripheral health units, with the role of each type of unit being appropriate to the human and material resources available to it. HIV-care services can also naturally integrate with the care of chronic noncommunicable diseases and with closely related services like mother and child health, and thus should promote a shift from vertical to integrated programming. Staff training and support around a set of evidence-based policies and guidelines and a reliable supply of essential medicines and supplies are further essential components for a successful programme.
AIDS 01/2012; 26:S97-S103. DOI:10.1097/QAD.0b013e32835bdde6 · 6.56 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Several frameworks have been constructed to analyse the factors which influence and shape the uptake of evidence into policy processes in resource poor settings, yet empirical analyses of health policy making in these settings are relatively rare. National policy making for cotrimoxazole (trimethoprim-sulfamethoxazole) preventive therapy in developing countries offers a pertinent case for the application of a policy analysis lens. The provision of cotrimoxazole as a prophylaxis is an inexpensive and highly efficacious preventative intervention in HIV infected individuals, reducing both morbidity and mortality among adults and children with HIV/AIDS, yet evidence suggests that it has not been quickly or evenly scaled-up in resource poor settings.
Comparative analysis was conducted in Malawi, Uganda and Zambia, using the case study approach. We applied the 'RAPID' framework developed by the Overseas Development Institute (ODI), and conducted a total of 47 in-depth interviews across the three countries to examine the influence of context (including the influence of donor agencies), evidence (both local and international), and the links between researcher, policy makers and those seeking to influence the policy process.
Each area of analysis was found to have an influence on the creation of national policy on cotrimoxazole preventive therapy (CPT) in all three countries. In relation to context, the following were found to be influential: government structures and their focus, donor interest and involvement, healthcare infrastructure and other uses of cotrimoxazole and related drugs in the country. In terms of the nature of the evidence, we found that how policy makers perceived the strength of evidence behind international recommendations was crucial (if evidence was considered weak then the recommendations were rejected). Further, local operational research results seem to have been taken up more quickly, while randomised controlled trials (the gold standard of clinical research) was not necessarily translated into policy so swiftly. Finally the links between different research and policy actors were of critical importance, with overlaps between researcher and policy maker networks crucial to facilitate knowledge transfer. Within these networks, in each country the policy development process relied on a powerful policy entrepreneur who helped get cotrimoxazole preventive therapy onto the policy agenda.
This analysis underscores the importance of considering national level variables in the explanation of the uptake of evidence into national policy settings, and recognising how local policy makers interpret international evidence. Local priorities, the ways in which evidence was interpreted, and the nature of the links between policy makers and researchers could either drive or stall the policy process. Developing the understanding of these processes enables the explanation of the use (or non-use) of evidence in policy making, and potentially may help to shape future strategies to bridge the research-policy gaps and ultimately improve the uptake of evidence in decision making.
Health Research Policy and Systems 06/2011; 9 Suppl 1(Suppl 1):S6. DOI:10.1186/1478-4505-9-S1-S6 · 1.86 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: In the April 2010 issue of this journal, Date et al. expressed concern over the slow scale-up in low-income settings of two therapies for the prevention of opportunistic infections in people living with the human immunodeficiency virus: co-trimoxazole prophylaxis and isoniazid preventive therapy. This short paper discusses the important ways in which policy analysis can be of use in understanding and explaining how and why certain evidence makes its way into policy and practice and what local factors influence this process. Key lessons about policy development are drawn from the research evidence on co-trimoxazole prophylaxis, as such lessons may prove helpful to those who seek to influence the development of national policy on isoniazid preventive therapy and other treatments. Researchers are encouraged to disseminate their findings in a manner that is clear, but they must also pay attention to how structural, institutional and political factors shape policy development and implementation. Doing so will help them to understand and address the concerns raised by Date et al. and other experts. Mainstreaming policy analysis approaches that explain how local factors shape the uptake of research evidence can provide an additional tool for researchers who feel frustrated because their research findings have not made their way into policy and practice.
Bulletin of the World Health Organisation 04/2011; 89(4):312-6. DOI:10.2471/BLT.10.077743 · 5.11 Impact Factor