From policy to action: how to operationalize the treatment for all agenda

Celletti, Francesca; Cohn, Jennifer; Connor, Catherine; Giphart, A; Montaner, Julio S. G.

doi:10.7448/ias.19.1.21185

Cited by 6 publications

(5 citation statements)

References 35 publications

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“…Second, health outreach programs for under-five care and family planning services could reduce women’s time burden for health care seeking, while extending the reach of health services. Efficiencies are also possible within HIV care and treatment through the use of differentiated models of care for ART distribution, such as providing 3–6 months of drug distribution at each ART visit, fast-track drug refills, and community-based ART distribution strategies [53–55].…”

Section: Discussionmentioning

confidence: 99%

Women's (health) work: A population-based, cross-sectional study of gender differences in time spent seeking health care in Malawi

2018

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BackgroundThere has been a notable expansion in routine health care in sub-Saharan Africa. While heath care is nominally free in many contexts, the time required to access services reflects an opportunity cost that may be substantial and highly gendered, reflecting the gendered nature of health care guidelines and patterns of use. The time costs of health care use, however, have rarely been systematically assessed at the population-level.MethodsData come from the 2015 wave of a population-based cohort study of young adults in southern Malawi during which 1,453 women and 407 men between the ages of 21 and 31 were interviewed. We calculated the time spent seeking health care over a two-month period, disaggregating findings by men, recently-pregnant women, mothers with children under two years old, and “other women”. We then extrapolated the time required for specific services to estimate the time that would be needed for each subpopulation to meet government recommendations for routine health services over the course of a year.ResultsApproximately 60% of women and 22% of men attended at least one health care visit during the preceding two months. Women spent six times as long seeking care as did men (t = -4.414, p<0.001), with an average 6.4 hours seeking care over a two-month period compared to 1 hour for men. In order to meet government recommendations for routine health services, HIV-negative women would need to spend between 19 and 63 hours annually seeking health care compared to only three hours for men. An additional 40 hours would be required of HIV-positive individuals initiating antiretroviral care.ConclusionsWomen in Malawi spend a considerable amount of time seeking routine health care services, while men spend almost none. The substantial time women spend seeking health care exacerbates their time poverty and constrains opportunities for other meaningful activities. At the same time, few health care guidelines pertain to men who thus have little interaction with the health care system. Additional public health strategies such as integration of services for those services frequently used by women and specific guidelines and outreach for men are urgently needed.

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Section: Discussionmentioning

confidence: 99%

Women's (health) work: A population-based, cross-sectional study of gender differences in time spent seeking health care in Malawi

2018

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“…The use of SMS reminders and the development of a tracking system including phone calls and home visits by community caregivers, as experienced in the TasP trial, have also been evaluated as effective to link [ 41 ] and retain people in care [ 42 ]. Secondly, as part of the differentiated ART delivery approach recommended by the WHO [ 43 ] aiming at simplifying HIV services and addressing the diversity of needs of people in care and treatment [ 44 , 45 ], the delivery of 3-month ART supplies for all stable individuals should be facilitated in all clinics. Thirdly, HCPs also reported on the importance of reducing stigma in health care system, through the integration of HIV services within general primary care services, and especially with other long-term conditions, as reported in another study conducted in another rural setting in South Africa [ 46 ].…”

Section: Discussionmentioning

confidence: 99%

Implementing universal HIV treatment in a high HIV prevalence and rural South African setting – Field experiences and recommendations of health care providers

et al. 2017

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BackgroundWe aimed to describe the field experiences and recommendations of clinic-based health care providers (HCP) regarding the implementation of universal antiretroviral therapy (ART) in rural KwaZulu-Natal, South Africa.MethodsIn Hlabisa sub-district, the local HIV programme of the Department of Health (DoH) is decentralized in 18 clinics, where ART was offered at a CD4 count ≤500 cells/μL from January 2015 to September 2016. Within the ANRS 12249 TasP trial, implemented in part of the sub-district, universal ART (no eligibility criteria) was offered in 11 mobile clinics between March 2012 and June 2016. A cross-sectional qualitative survey was conducted in April–July 2016 among clinic-based nurses and counsellors providing HIV care in the DoH and TasP trial clinics. In total, 13 individual interviews and two focus groups discussions (including 6 and 7 participants) were conducted, audio-recorded, transcribed, and thematically analyzed.ResultsAll HCPs reported an overall good experience of delivering ART early in the course of HIV infection, with most patients willing to initiate ART before being symptomatic. Yet, HCPs underlined that not feeling sick could challenge early ART initiation and adherence, and thus highlighted the need to take time for counselling as an important component to achieve universal ART. HCPs also foresaw logistical challenges of universal ART, and were especially concerned about increasing workload and ART shortage. HCPs finally recommended the need to strengthen the existing model of care to facilitate access to ART, e.g., community-based and integrated HIV services.ConclusionsThe provision of universal ART is feasible and acceptable according to HCPs in this rural South-African area. However their experiences suggest that universal ART, and more generally the 90-90-90 UNAIDS targets, will be difficult to achieve without the implementation of new models of health service delivery.

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“…These interventions are implemented in different combinations and with varying quality across HIV programmes , and operationalization of Treat‐All may be challenging in weak health systems . Despite adoption of the Treat‐All policy by many countries , questions remain about the feasibility of ongoing ART expansion and provision of quality care in resource‐poor health settings , with many operational challenges anticipated .…”

Section: Introductionmentioning

confidence: 99%

Feasibility of antiretroviral therapy initiation under the treat‐all policy under routine conditions: a prospective cohort study from Eswatini

et al. 2019

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Introduction The World Health Organization recommends the Treat‐All policy of immediate antiretroviral therapy (ART) initiation, but questions persist about its feasibility in resource‐poor settings. We assessed the feasibility of Treat‐All compared with standard of care (SOC) under routine conditions. Methods This prospective cohort study from southern Eswatini followed adults from HIV care enrolment to ART initiation. Between October 2014 and March 2016, Treat‐All was offered in one health zone and SOC according to the CD4 350 and 500 cells/mm3 treatment eligibility thresholds in the neighbouring health zone, each of which comprised one secondary and eight primary care facilities. We used Kaplan–Meier estimates, multivariate flexible parametric survival models and standardized survival curves to compare ART initiation between the two interventions. Results Of the 1726 (57.3%) patients enrolled under Treat‐All and 1287 (42.7%) under SOC, cumulative three‐month ART initiation was higher under Treat‐All (91%) than SOC (74%; p < 0.001) with a median time to ART of 1 (IQR 0 to 14) and 10 (IQR 2 to 117) days respectively. Under Treat‐All, ART initiation was higher in pregnant women (vs. non‐pregnant women: adjusted hazard ratio (aHR) 1.96, 95% confidence interval (CI) 1.70 to 2.26), those with secondary education (vs. no formal education: aHR 1.48, 95% CI 1.12 to 1.95), and patients with an HIV‐positive diagnosis before care enrolment (aHR 1.22, 95% CI 1.10 to 1.36). ART initiation was lower in patients attending secondary care facilities (aHR 0.64, 95% CI 0.58 to 0.72) and for CD4 351 to 500 when compared with CD4 201 to 350 cells/mm3 (aHR 0.84, 95% CI 0.72 to 1.00). ART initiation varied over time for TB cases, with lower hazard during the first two weeks after HIV care enrolment and higher hazards thereafter. Of patients with advanced HIV disease (n = 1085; 36.0%), crude 3‐month ART initiation was similar in both interventions (91% to 92%) although Treat‐All initiated patients more quickly during the first month after HIV care enrolment. Conclusions ART initiation was high under Treat‐All and without evidence of de‐prioritization of patients with advanced HIV disease. Additional studies are needed to understand the long‐term impact of Treat‐All on patient outcomes.

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From policy to action: how to operationalize the treatment for all agenda

Cited by 6 publications

References 35 publications

Women's (health) work: A population-based, cross-sectional study of gender differences in time spent seeking health care in Malawi

Women's (health) work: A population-based, cross-sectional study of gender differences in time spent seeking health care in Malawi

Implementing universal HIV treatment in a high HIV prevalence and rural South African setting – Field experiences and recommendations of health care providers

Feasibility of antiretroviral therapy initiation under the treat‐all policy under routine conditions: a prospective cohort study from Eswatini

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