From scaling up to sustainability in HIV: potential lessons for moving forward

Abstract

BackgroundIn 30 years of experience in responding to the HIV epidemic, critical decisions and program characteristics for successful scale-up have been studied. Now leaders face a new challenge: sustaining large-scale HIV prevention programs. Implementers, funders, and the communities served need to assess what strategies and practices of scaling up are also relevant for sustaining delivery at scale.MethodsWe reviewed white and gray literature to identify domains central to scaling-up programs and reviewed HIV case studies to identify how these domains might relate to sustaining delivery at scale.ResultsWe found 10 domains identified as important for successfully scaling up programs that have potential relevance for sustaining delivery at scale: fiscal support; political support; community involvement, integration, buy-in, and depth; partnerships; balancing flexibility/adaptability and standardization; supportive policy, regulatory, and legal environment; building and sustaining strong organizational capacity; transferring ownership; decentralization; and ongoing focus on sustainability. We identified one additional potential domain important for programs sustaining delivery at scale: emphasizing equity.ConclusionsToday, the public and private sector are examining their ability to generate value for populations. All stakeholders are aiming to stem the tide of the HIV epidemic. Implementers need a framework to guide the evolution of their strategies and management practices. Greater research is needed to refine the domains for policy and program implementers working to sustain HIV program delivery at scale.

Modifications to ART service delivery models by health facilities in Uganda in promotion of intervention sustainability: a mixed methods study

“…The literature on health program sustainability has referred to this distinction as one between the core components and the customizable components of interventions [15–17, 23]. Hirschhorn et al [13] have called for an appropriate balance between adaptation and flexibility in the scale-up of HIV interventions [46]. In contrast with a previous study [45], we found that most modifications to ART were made at the organization level as opposed to individual clinicians.…”

“…Devising service delivery models that are suited to resource-limited contexts is acknowledged as an important strategy for fostering the sustainability of ART scale-up programs in SSA [10, 11]. Service delivery design alternatives to the traditional model of physician-centered, clinic-based care are becoming critical in SSA [4, 12, 13]. Sustaining and expanding ART coverage in resource-limited settings requires modifications and adaptations of ART delivery models to meet the continually rising demand [10, 11].…”

The pitfalls of scaling up evidence-based interventions in health

“…They related to cost-effectiveness, equity, harms, ethics, bottom-up/top-down scaling-up, and the context in which the EBI was scaled up (see Figure 2). To discuss them, we identified 45 scaling-up studies that raised these difficulties, of which 13 were on costeffectiveness estimates or cost-analysis models [22][23][24][25][26][27][28][29][30][31][32][33][34], 14 on equity [35][36][37][38][39][40][41][42][43][44][45][46][47][48], four on harms [16,[49][50][51][52], three on ethics [53][54][55], six on top-down implementation [42,[56][57][58][59][60], and eight on contextual problems [40,43,[61][62][63][64]…”

“…The health inequities pitfall: some people will necessarily be left out Many studies highlight equity as a motive for scalingup effective healthcare interventions: an EBI that is delivered only to a small population constitutes a health inequity, as others are deprived of its proven health benefits [36,[38][39][40]42,43,[46][47][48].…”

Globalization and Health: developing the journal to advance the field

“…Research focused on the transmission of communicable diseases, and the influence that globalisation has on the spread of these [34, 35]. Most papers were in relation to HIV and AIDS, and included HIV programme sustainability, access to interventions and adherence to treatments [17, 36, 37]. Sustained use and access to antiretroviral therapy was another frequently occurring topic under this construct.…”