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

ArticleinTransactions of the Royal Society of Tropical Medicine and Hygiene 102(4):310-1 · May 2008with7 Reads
DOI: 10.1016/j.trstmh.2008.01.005 · Source: PubMed
Abstract
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.
    • "This increased demand has necessitated a shift away from a medical model of care, primarily used in resource-rich countries and relying on highly trained medical personnel in specialized healthcare facilities to provide individualized HIV care and treatment, to a public health model that delivers treatment to more individuals [3]. The public health model relies on decentralization of HIV services to increase access, particularly in rural areas, task-shifting of activities to overcome the dearth of healthcare personnel [4], and standardized and simplified regimens and care packages to facilitate administration of care and treatment to large numbers of patients [5]. Different strategies for decentralizing HIV services have been developed in sub-Saharan African countries that are adapted to local conditions, influenced by varying roles of donor support, and incorporate lessons learned over the past decade. "
    [Show abstract] [Hide abstract] ABSTRACT: Background Travel time and distance are barriers to care for HIV-infected children in rural sub-Saharan Africa. Decentralization of care is one strategy to scale-up access to antiretroviral therapy (ART), but few programs have been evaluated. We compared outcomes for children receiving care in mobile and hospital-affiliated HIV clinics in rural Zambia. Methods Outcomes were measured within an ongoing cohort study of HIV-infected children seeking care at Macha Hospital, Zambia from 2007 to 2012. Children in the outreach clinic group received care from the Macha HIV clinic and transferred to one of three outreach clinics. Children in the hospital-affiliated clinic group received care at Macha HIV clinic and reported Macha Hospital as the nearest healthcare facility. Results Seventy-seven children transferred to the outreach clinics and were included in the analysis. Travel time to the outreach clinics was significantly shorter and fewer caretakers used public transportation, resulting in lower transportation costs and fewer obstacles accessing the clinic. Some caretakers and health care providers reported inferior quality of service provision at the outreach clinics. Sixty-eight children received ART at the outreach clinics and were compared to 41 children in the hospital-affiliated clinic group. At ART initiation, median age, weight-for-age z-scores (WAZ) and CD4+ T-cell percentages were similar for children in the hospital-affiliated and outreach clinic groups. Children in both groups experienced similar increases in WAZ and CD4+ T-cell percentages. Conclusions HIV care and treatment can be effectively delivered to HIV-infected children at rural health centers through mobile ART teams, removing potential barriers to uptake and retention. Outreach teams should be supported to increase access to HIV care and treatment in rural areas.
    Full-text · Article · Aug 2014
    • "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). Though much has changed and is still changing in Mozambique, through political and health systems transition, its colonial legacy nevertheless plays an important role for its national responses to infectious disease epidemics, including HIV. "
    [Show abstract] [Hide abstract] 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.
    Article · Feb 2014
    • "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). "
    [Show abstract] [Hide abstract] 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.
    Full-text · Article · Mar 2013
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