Abstract
BackgroundConsiderable debate exists concerning the effects of antiretroviral therapy (ART) service scale-up on non-HIV services and overall health system performance in sub-Saharan Africa. In this study, we examined whether ART services affected trends in non-ART outpatient department (OPD) visits in Kenya and Uganda.MethodsUsing a nationally representative sample of health facilities in Kenya and Uganda, we estimated the effect of ART programs on OPD visits from 2007 to 2012. We modeled the annual percent change in non-ART OPD visits using hierarchical mixed-effects linear regressions, controlling for a range of facility characteristics. We used four different constructs of ART services to capture the different ways in which the presence, growth, overall, and relative size of ART programs may affect non-ART OPD services.ResultsOur final sample included 321 health facilities (140 in Kenya and 181 in Uganda). On average, OPD and ART visits increased steadily in Kenya and Uganda between 2007 and 2012. For facilities where ART services were not offered, the average annual increase in OPD visits was 4·2% in Kenya and 13·5% in Uganda. Among facilities that provided ART services, we found average annual OPD volume increases of 7·2% in Kenya and 5·6% in Uganda, with simultaneous annual increases of 13·7% and 12·5% in ART volumes. We did not find a statistically significant relationship between annual changes in OPD services and the presence, growth, overall, or relative size of ART services. However, in a subgroup analysis, we found that Ugandan hospitals that offered ART services had statistically significantly less growth in OPD visits than Ugandan hospitals that did not provide ART services.ConclusionsOur findings suggest that ART services in Kenya and Uganda did not have a statistically significant deleterious effects on OPD services between 2007 and 2012, although subgroup analyses indicate variation by facility type. Our findings are encouraging, particularly given recent recommendations for universal access to ART, demonstrating that expanding ART services is not inherently linked to declines in other health services in sub-Saharan Africa.
Highlights
Considerable debate exists concerning the effects of antiretroviral therapy (ART) service scale-up on non-HIV services and overall health system performance in sub-Saharan Africa
Looking at facility type, we found that in Ugandan hospitals, average annual outpatient department (OPD) visits increased more than three times faster in hospitals that did not provide ART services (16·5% vs. 4·5%)
We found that the presence, scale-up, and size of facility-based ART programs had no statistically significant effects on OPD visits over time
Summary
Considerable debate exists concerning the effects of antiretroviral therapy (ART) service scale-up on non-HIV services and overall health system performance in sub-Saharan Africa. Due to an unprecedented global response, the rate of new HIV infections has declined and an estimated 19·1 million life-years have been saved by interventions such as antiretroviral therapy (ART) [2] Such gains have been driven by a rapid increase in HIV-specific development assistance for health (DAH), which rose in real terms from $1·4 billion in 2000 to $11 billion in 2015 [3]. Access to and enrollment in ART programs markedly increased in the last decade, [1, 4] providing life-saving treatment for people living with HIV throughout the world Amid this success, considerable debate exists about how this massive scale-up of ART has affected the provision of non-HIV services [5,6,7]. With HIV-targeted DAH stagnating since 2010 [3] and new treatment guidelines recommending universal access to ART, [8] understanding if and where the scale-up of ART services has had beneficial or detrimental health system effects is critical
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