Abstract
BackgroundIn November 2015, WHO released new treatment guidelines recommending that all diagnosed as HIV positive be enrolled on antiretroviral therapy (ART). Sustaining and expanding ART scale-up programs in resource-limited settings will require adaptations and modifications to traditional ART delivery models to meet the rapid increase in demand. We identify modifications to ART service delivery models by health facilities in Uganda to sustain ART interventions over a 10-year period (2004–2014).MethodsA mixed methods approach involving two study phases was adopted. In the first phase, a survey of a nationally representative sample of health facilities (n = 195) in Uganda which were accredited to provide ART between 2004 and 2009 was conducted. The second phase involved semi-structured interviews (n = 18) with ART clinic managers of 6 of the 195 health facilities purposively selected from the first study phase. We adopted a thematic framework consisting of four categories of modifications (format, setting, personnel, and population).ResultsThe majority of health facilities 185 (95%) reported making modifications to ART interventions between 2004 and 2014. Of the 195 health facilities, 157 (81%) rated the modifications made to ART as “major.” Modifications to ART were reported under all the four themes. The quantitative and qualitative findings are integrated and presented under four themes. Format: Reducing the frequency of clinic appointments and pharmacy-only refill programs was identified as important strategies for decongesting ART clinics. Setting: Home-based care programs were introduced to reduce provider ART delivery costs. Personnel: Task shifting to non-physician cadre was reported in 181 (93%) of the health facilities. Population: Visits to the ART clinic were rationalized in favor of the sub-population deemed to have more clinical need. Two health facilities focused on patients living nearer the health facilities to align with targets set by external donors.ConclusionsOver the study period, health facilities made several modifications ART interventions to improve fit with their resource-constrained settings thereby promoting long-term sustainability. Further research evaluating the effect of these modifications on patient outcomes and ART delivery costs is recommended. Our findings have implications for the sustainability of ART scale-up programs in Uganda and other resource-limited settings.
Highlights
In November 2015, WHO released new treatment guidelines recommending that all diagnosed as HIV positive be enrolled on antiretroviral therapy (ART)
In November 2015, WHO released new ART treatment guidelines recommending that all diagnosed as HIV positive be enrolled on sustained ART regardless of disease stage [1]
Almost half of the health facilities 88 (45%) were located in peri-urban settings compared to 78 (40%) which were in located in urban settings and 29 (15%) which were based in rural settings
Summary
In November 2015, WHO released new treatment guidelines recommending that all diagnosed as HIV positive be enrolled on antiretroviral therapy (ART). Universal access to antiretroviral treatment (ART) is taking on increasing importance as a global public health priority. In November 2015, WHO released new ART treatment guidelines recommending that all diagnosed as HIV positive be enrolled on sustained ART regardless of disease stage [1]. In September 2015, the Sustainable Development Goals (SDGs) retained the goal of universal access to HIV treatment in the new international development agenda [2]. PEPFAR and The Global Fund supported a rapid expansion in ART coverage in SSA in an approach later known as WHO’s public health approach of ART roll-out to the largest number of HIV-positive people possible [4]. There are indications that international investments for ART scale-up are undergoing a slowdown and even declining according to some estimates [5,6,7]
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