HIV policy implementation in two health and demographic surveillance sites in Uganda: findings from a national policy review, health facility surveys and key informant interviews

Ellen Mcrobie,Jessica Nakiyingi-Miiro,Francis Kiweewa,Tom Lutalo,Basia Zaba,Alison Wringe,Gertrude Nakigozi,Jim Todd,Jeffrey William Eaton,Kathryn Church

doi:10.1186/s13012-017-0574-z

Abstract

BackgroundSuccessful HIV testing, care and treatment policy implementation is essential for realising the reductions in morbidity and mortality those policies are designed to target. While adoption of new HIV policies is rapid, less is known about the facility-level implementation of new policies and the factors influencing this.MethodsWe assessed implementation of national policies about HIV testing, treatment and retention at health facilities serving two health and demographic surveillance sites (HDSS) (10 in Kyamulibwa, 14 in Rakai). Ugandan Ministry of Health HIV policy documents were reviewed in 2013, and pre-determined indicators were extracted relating to the content and nature of guidance on HIV service provision. Facility-level policy implementation was assessed via a structured questionnaire administered to in-charge staff from each health facility. Implementation of policies was classified as wide (≥75% facilities), partial (26–74% facilities) or minimal (≤25% facilities). Semi-structured interviews were conducted with key informants (policy-makers, implementers, researchers) to identify factors influencing implementation; data were analysed using the Framework Method of thematic analysis.ResultsMost policies were widely implemented in both HDSS (free testing, free antiretroviral treatment (ART), WHO first-line regimen as standard, Option B+). Both had notable implementation gaps for policies relating to retention on treatment (availability of nutritional supplements, support groups or isoniazid preventive therapy). Rakai implemented more policies relating to provision of antiretroviral treatment than Kyamulibwa and performed better on quality of care indicators, such as frequency of stock-outs. Factors facilitating implementation were donor investment and support, strong scientific evidence, low policy complexity, phased implementation and effective planning. Limited human resources, infrastructure and health management information systems were perceived as major barriers to effective implementation.ConclusionsMost HIV policies were widely implemented in the two settings; however, gaps in implementation coverage prevail and the value of ensuring complete coverage of existing policies should be considered against the adoption of new policies in regard to resource needs and health benefits.

Highlights

Data from two health and demographic surveillance sites (HDSS) in rural Uganda indicate that while mortality had substantially declined since the introduction of anti-retroviral treatment (ART) in 2004, there continues to be substantially higher mortality in the Human immunodeficiency virus (HIV)-positive population compared to the HIV-negative population (HIVnegative mortality rates were 8.6 deaths and 3.4 deaths per 1000 person years for Kyamulibwa and Rakai, respectively) (Table 1) [6]
This study aims to compare the status of implementation of policies promoting access to HIV testing, treatment and retention on treatment for facilities serving the population of two health and demographic surveillance sites (HDSS) in southern Uganda: Kyamulibwa and Rakai
Human resources were similar across both sites in regard to median numbers of clinicians, nurses/midwives and counsellors in facilities; there were stark disparities in the staff to client ratios: Rakai had much higher numbers of patients per staff member per week for HIV counselling and testing (HCT) (58 clients per week, compared to 19 per week in Kyamulibwa) and ART (49 per week, compared to 3 per week in Kyamulibwa)

Summary

Introduction

Recent systematic reviews suggest heavy attrition of people living with HIV (PLHIV) at all stages of the care continuum, resulting in persistently higher mortality in the HIV-positive population compared to those who are HIV negative [4]. This raises the question about the extent to which appropriate policies exist, the extent to which they are implemented and factors that facilitate or disable policy implementation.

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