A longitudinal review of national HIV policy and progress made in health facility implementation in Eastern Zimbabwe

Kathryn Church,Edith Mpandaguta,Simon Gregson,Rebecca Rhead,Owen Mugurungi,Jeffrey W. Eaton,Nimalan Arinaminpathy,Noah Kadzura,Malebogo Tlhajoane,Constance Nyamukapa,Tidings Masoka,Nadine Schur,Alison Wringe,Morten Skovdal

doi:10.1186/s12961-018-0358-1

Abstract

BackgroundIn recent years, WHO has made major changes to its guidance on the provision of HIV care and treatment services. We conducted a longitudinal study from 2013 to 2015 to establish how these changes have been translated into national policy in Zimbabwe and to measure progress in implementation within local health facilities.MethodsNational HIV programme policy guidelines published between 2003 and 2013 (n = 9) and 2014 and 2015 (n = 5) were reviewed to assess adoption of WHO recommendations on HIV testing services, prevention of mother-to-child transmission (PMTCT) of HIV, and provision of antiretroviral therapy (ART). Changes in local implementation of these policies over time were measured in two rounds of a survey conducted at 36 health facilities in Eastern Zimbabwe in 2013 and 2015.ResultsHigh levels of adoption of WHO guidance into national policy were recorded, including adoption of new recommendations made in 2013–2015 to introduce PMTCT Option B+ and to increase the threshold for ART initiation from CD4 ≤ 350 cells/mm3 to ≤ 500 cells/mm3. New strategies to implement national HIV policies were introduced such as the decentralisation of ART services from hospitals to clinics and task-shifting of care from doctors to nurses. The proportions of health facilities offering free HIV testing and counselling, PMTCT (including Option B+) and ART services increased substantially from 2013 to 2015, despite reductions in numbers of health workers. Provision of provider-initiated HIV testing remained consistently high. At least one test-kit stock-out in the prior year was reported in most facilities (2013: 69%; 2015: 61%; p = 0.44). Stock-outs of first-line ART and prophylactic drugs for opportunistic infections remained low. Repeat testing for HIV-negative individuals within 3 months decreased (2013: 97%; 2015: 72%; p = 0.01). Laboratory testing remained low across both survey rounds, despite policy and operational guidelines to expand coverage of diagnostic services.ConclusionsGood progress has been made in implementing international guidance on HIV service delivery in Zimbabwe. Further novel implementation strategies may be needed to achieve the latest targets for universal ART eligibility.

Highlights

In recent years, WHO has made major changes to its guidance on the provision of HIV care and treatment services
The Joint United Nations Programme for HIV/AIDS (UNAIDS) estimates indicate that, in 2015, there were 36.7 million people living with HIV (PLHIV) worldwide, of whom 66% lived in sub-Saharan Africa [1]
New national guidelines on the use of Antiretroviral therapy (ART) in Zimbabwe were released in November 2013, in which two key changes in national HIV treatment policy were noted

Summary

Introduction

WHO has made major changes to its guidance on the provision of HIV care and treatment services. Antiretroviral therapy (ART) has been shown to be highly efficacious in reducing mortality, improving the immunological status of PLHIV and reducing onward transmission of HIV [2,3,4,5]. As evidence of these benefits has grown, WHO recommendations have been revised over time to expand eligibility for ART. To drive progress in implementing the latest WHO guidelines, UNAIDS set the 90–90–90 treatment targets, specifying that 90% of PLHIV should be diagnosed and aware of their sero-status, 90% of those diagnosed should be receiving ART and 90% of those on ART should be virologically suppressed by the year 2020 [11]

Methods

Results

Conclusion