Antiretroviral Treatment

Poverty and limited health services in rural Africa present barriers to adherence to antiretroviral therapy that necessitate innovative options other than facility-based methods for delivery and monitoring of such therapy. We assessed adherence to antiretroviral therapy in a cohort of HIV-infected people in a home-based AIDS care programme that provides the therapy and other AIDS care, prevention, and support services in rural Uganda. [author’s description]

Action is underway to increase access to antiretroviral drugs, especially in countries with high rates of HIV. The role of private providers is largely ignored, although they are an important source of care for stigmatizing diseases in many poor countries. Evidence is emerging that antiretroviral drugs are leaking into formal and informal private markets. Uncontrolled use of drugs in the private sector will lead to rapid development of HIV resistance. Countries require guidance and support from international policy makers and pharmaceutical companies to implement strategies for working with private providers.

This presentation was given as part of the Christian Health Association’s Conference: CHAs at a Crossroad Towards Achieving Health Millennium Development Goals. It provides an excellent overview of the challenges of Malaria and HIV/AIDS ; discusses the human resource needs in light of these challenges; and how to build and maintain capacity. [from author’s description]

The main objections to the use of [antiretroviral therapies] in less-developed countries have been their high cost and the lack of health infrastructure necessary to use them. We have shown that it is possible to carry out an HIV treatment programme in a poor community in rural Haiti, the poorest country in the western hemisphere.

[This case study evaluates the] Drug Resources Enhancement against AIDS and Malnutrition (DREAM) program, created by the Community of Sant’Egidio to fight AIDS in sub-Saharan Africa. The project takes a holistic approach, combining Highly Active Anti- Retroviral Therapy (HAART) with the treatment of malnutrition, tuberculosis, malaria, and sexually transmitted diseases. It also strongly emphasizes health education at all levels. DREAM aims to achieve its goals in line with the gold standard for HIV treatment and care. [author’s description]

Efforts to increase access to life-saving treatment, including antiretroviral therapy (ART), for people living with HIV/AIDS in resource-limited settings has been the growing focus of international efforts. One of the greatest challenges to scaling up will be the limited supply of adequately trained human resources for health, including doctors, nurses, pharmacists and other skilled providers.

The Nigerian national ARV treatment training programme was conceived to meet the human resource needs in hospitals providing ARV therapy. This paper reports on the evaluation of the training programme. It examines knowledge and skills gained, and utilization thereof. Recommendations are made for improved training effectiveness and for specific national policy on training, to meet the demand for scaling up therapy to the thousands who need ARV. [from abstract]

A number of ART projects are trying to tackle the HRH problematic by delegating certain tasks from medical doctors to other cadres. While this task-shifting is certainly an important step, we contend that it will not be enough for scaling up ART in the high HIV-prevalence countries with the most severe HRH shortages. In the present report we argue that an altogether different approach to HIV/AIDS care and treatment might be required for overcoming the HRH bottleneck. [from summary]

The researchers conclude that given the HRH crisis, ART delivery models requiring much less doctor time need to be developed. Overall, there is a need to shift tasks from medical doctors to nurses and from nurses to community health workers. In particular, the patients themselves need to play an important role in the delivery of ART. The outcomes of the various scenarios are predicted. [from author]

This study provides evidence on the cost of providing HAART to health care workers and suggests that this strategy could reduce absenteeism and alleviate future staff shortages at moderate cost to hospitals. This is crucial, given the impending human resources crisis in health care in South Africa and the growing burden of HIV/AIDS. These cost estimates should be good indicators of the costs of extending antiretroviral therapy to health care workers in public-sector hospitals in KwaZulu-Natal. [author’s description]

This document evaluates the Support and Treatment for Antiretroviral Therapy project (START) program, a joint initiative of Family Health International (FHI) and the Government of Ghana, to integrate antiretroviral therapy into comprehensive care for people living with HIV/AIDS in Ghana. START helped establish voluntary counseling and testing centers, prevention of mother-to-child transmission activities and clinical care services. Key components of the START program include home-based care (HBC), referral networks and linkages to such existing services as spiritual and social support, and support for orphans and other vulnerable children (OVC).

This guideline is for human resources planners and managers in the health sector and sets out the steps required to extend the health workforce by incorporating lay workers (field officers), especially in the delivery of antiretroviral therapy (ART) to home-based clients.

This is a guideline to replicate and scale-up a human resources promising practice documented by the Capacity Project for outsourcing human resources services (HRS) to obtain a rapid increase and deployment of the health workforce, making HIV services available in a short period of time, especially in underserved areas.

The following guidelines have been developed by a working group of practitioners drawn from clinics, hospitals, congregations and communities. They are intended for use by practitioners from the congregation, community, clinic, and other partners in local responses which are incorporating ART. [Description from preface]

This paper reviews the experiences of franchising and discusses the opportunities and implications for governments and donors of franchising for HIV and AIDS services. [from author]

Funding for scaling-up antiretroviral treatment (ART) in low-income countries has increased substantially, but the lack of human resources for health (HRH) is increasingly being identified as an important constraint for scaling-up ART. ART is labour intensive. Important reductions in doctor-time per patient can be realized during scaling-up. The doctor-based ART delivery model analysed seems adequate for Cambodia. However, for many districts in sub-Saharan Africa a doctor-based ART delivery model may be incompatible with their HRH constraints. [from abstract]

This article focuses on professional nurses in a study of patterns of planning, recruitment, training and task allocation associated with an expanding antiretroviral program in the districts of Free State. [from abstract]

The lack of Human Resources for Health (HRH) is increasingly being recognized as a major bottleneck for scaling-up anti-retroviral treatment (ART), particularly in sub-Saharan Africa. This paper sets out (1) to describe the present HRH situation in sub-Saharan Africa, (2) to analyze the consequence of this on ART delivery and scale-up, and (3) to map the main actors in the international HRH arena. [Description from authors]

Limited human resources to treat HIV/AIDS (HRHA) are one of the main constraints to achieving universal ART coverage. We model the gap between needed and available HRHA to quantify the challenge of achieving and sustaining universal ART coverage by 2017. [from abstract]

Twelve percent of the adult population in Malawi is estimated to be HIV infected and 15% to 20% of these are in need of life saving antiretroviral therapy. Using data on the total number of patients on highly active antiretroviral treatment (HAART) and estimates of the number of health professionals required to deliver HAART, researchers set out to determine the human resources requirements for HAART scale-up in Malawi. Results show that the human resources requirements are significant and that Malawi is using far fewer human resources than would be expected based on past studies. [adapted

In the space of just a few years, close to 300,000 people with HIV have been put onto ART in Ethiopia and Malawi

The AIDS Support Organization (TASO) administers a home-based program in Uganda that gives people in poor and rural settings access to antiretroviral therapy (ART) and services. The program’s innovation lies in shifting delivery of most clients’ follow-up activities at home to field officers, a new cadre of degree and diploma holders from the social sciences and education. Field officers ensure adherence to ART, refill clients’ medications and perform various activities, from voluntary counseling and testing to education to promoting family and community support. [from executive summary]

The WHO IMAI guidelines support the rapid expansion of access to ART by supporting the shifts of key tasks to multi-purpose health workers at first-level facilities located in the community (health centres and clinics). By preparing nurses and clinical aids to provide acute care to adults, many opportunistic infections can be treated and the patient stabilized for ARV treatment without referral to district clinic. Management of patients near their home is important for equity and to achieve high levels of ARV adherence. [adapted from publisher’s description]

As strides are made in the prevention and treatment of HIV, it is important to take advantage of opportunities to expand and integrate reproductive health services. Integration is an approach that uses a client visit as an opportunity to address other health and social needs beyond those that prompted the current health visit.

To maximize program impact with current resources, integration of Family Planning into existing HIV/AIDS programs is a very cost effective and an excellent point of entry. This is a study of an intervention program focused on initiating and also strengthening existing integration of FP into functional VCT, ART and PMTCT sites. The intervention encompassed an orientation on integration benefits to heads of health facilities; identification of challenges of integration and drawing of plan of action on how to overcome the challenges and improve integration. Major challenges identified were related both to health workers, such as high workload, staff burnout and turnover, as well as to efforts in scaling up of facilities operations to adequately incorporate integration activities. [from abstract]

In order to identify potentially effective models of home-based care (HBC) within which paediatric palliative care could be integrated, and to identify critical aspects requiring strengthening, the NMCF commissioned an in-depth evaluation of three NGOs that have been supported through the Goelama Program. The objectives of the evaluation were: to evaluate the current capacity of the three HBC projects to provide paediatric palliative care as a component of overall HBC - this focused on the overall management of the projects, as well as the competencies of carers to provide both general HBC and palliative care to children; To explore the possibilities for strengthening the provision of paediatric palliative care as an integrated component of HBC; and to explore the role of home-based carers and HBC projects in the provision of ART to children. [author’s description]

This report documents the assessment of a family planning training program for providers to enable them to offer family planning counseling and methods, and make referrals where needed as part of antiretroviral therapy services in Ghana. [from summary]

Sub-Saharan Africa is the epicenter of the HIV/AIDS epidemic. An assessment of health-care worker availability in the region against health system needs for that area reveals stark gaps. This article details the contributing reasons for health-care worker shortages, as well as the effect of these shortages on antiretroviral therapy (ART) for HIV-infected patients. [from abstract]

The Lesotho apparel industry is the country’s largest private sector employer. By providing employment for poor and relatively unskilled workers, most of whom are women, this industry is combating two of the key long-term drivers of the HIV/AIDS epidemic: poverty and gender inequity. However, it is precisely this sector of the community, young women, who have the highest prevalence of HIV infection. Studies within the apparel sector show that around one third of employees are HIV-positive. Apart from the huge toll in human suffering associated with this high infection level, the epidemic also lowers productivity and increases costs to the employer. The Lesotho government is committed to providing a comprehensive response to HIV/AIDS, including the provision of antiretroviral treatment (ART) but, because of a lack of financial and human resources, only about 8 000 Basotho are receiving treatment at present. It is estimated that about 60 000 Basotho require ART. For all these reasons, a range of stakeholders wished to determine the feasibility of a private sector led long-term intervention (LTI) to reduce the HIV-infection rate among apparel workers and to provide care and support for those already infected. Towards this end consulting company HLSP was contracted to conduct this feasibility study and this report and specific recommendations are the outcome of the project. [author’s description]

This report describes global progress on the “3 by 5” (Treating 3 million by 2005: making it happen) project in scaling up access to [HIV/AIDS] antiretroviral therapy and outlines the areas in which important progress has been made and lessons learned. It also outlines the remaining challenges and roadblocks to treatment access. [author’s description]

Chapter 2 (Strengthening Health Systems) provides an overview of HRH related approaches and progress.