Identifying gaps in HIV policy and practice along the HIV care continuum: evidence from a national policy review and health facility surveys in urban and rural Kenya

Caoimhe Cawley,Frank Odhiambo,Ellen Mcrobie,Jim Todd,Brian Njamwea,Basia Zaba,Tara Shoham,Alison Wringe,Paul Mee,Muthoni Njage,Amek Nyaguara,Kathryn Church,Georges Reniers,Fredrick Otieno,Samuel Oti

doi:10.1093/heapol/czx091

Abstract

The last decade has seen rapid evolution in guidance from the WHO concerning the provision of HIV services along the diagnosis-to-treatment continuum, but the extent to which these recommendations are adopted as national policies in Kenya, and subsequently implemented in health facilities, is not well understood. Identifying gaps in policy coverage and implementation is important for highlighting areas for improving service delivery, leading to better health outcomes. We compared WHO guidance with national policies for HIV testing and counselling, prevention of mother-to-child transmission, HIV treatment and retention in care. We then investigated implementation of these national policies in health facilities in one rural (Kisumu) and one urban (Nairobi) sites in Kenya. Implementation was documented using structured questionnaires that were administered to in-charge staff at 10 health facilities in Nairobi and 34 in Kisumu. Policies were defined as widely implemented if they were reported to occur in > 70% facilities, partially implemented if reported to occur in 30–70% facilities, and having limited implementation if reported to occur in < 30% facilities. Overall, Kenyan national HIV care and treatment policies were well aligned with WHO guidance. Policies promoting access to treatment and retention in care were widely implemented, but there was partial or limited implementation of several policies promoting access to HIV testing, and the more recent policy of Option B+ for HIV-positive pregnant women. Efforts are needed to improve implementation of policies designed to increase rates of diagnosis, thus facilitating entry into HIV care, if morbidity and mortality burdens are to be further reduced in Kenya, and as the country moves towards universal access to antiretroviral therapy.

Highlights

Over the last 10–15 years, the provision and uptake of HIV testing services has increased dramatically in sub-Saharan Africa, as has the number of people living with HIV (PLHIV) who are receiving antiretroviral therapy (ART)
The patient load or burden per staff member was higher for ART provision than for HIV testing service provision (while national policies recommend a maximum number of HIV testing clients (n 1⁄4 15) per healthcare worker per day, there is no such recommendation for ART clients)
We identified a close alignment between Kenyan national policies on HIV care and treatment and guidelines produced by the WHO, with a few instances of policy gaps in the areas of prevention of mother-to-child transmission (PMTCT), access to ART and retention in care

Summary

Introduction

Over the last 10–15 years, the provision and uptake of HIV testing services has increased dramatically in sub-Saharan Africa, as has the number of people living with HIV (PLHIV) who are receiving antiretroviral therapy (ART). Rates of HIV testing remain sub-optimal in many countries (Venkatesh et al 2011; Baggaley et al 2012; Cawley et al 2013).

Methods

Results

Conclusion