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countries, the barriers and facilitators to WHO and ART Theme 2: The timely implementation of World Health
initiation policy adoption in SSA and the similarities in Organization antiretroviral therapy initiation policy
country characteristics in policy implementation in different guidelines at country level
SSA countries. Teasdale et al. describe high rates of early – within 3 months –
ART initiation amongst ART-eligible Rwandan patients.
Ethical consideration Indeed, by 2012, the Rwanda National HIV Care and
Treatment Programme had managed to initiate 94% of
Ethical approval was obtained from the University of eligible PLWH on ART in line with the 2006 and 2010 WHO
KwaZulu-Natal Biomedical Research Ethics Committee guidelines. Rwanda was also one of the first countries in SSA
(UKZN BREC, reference number: BREC/00000819/ 2019). to implement the higher CD4+ initiation threshold for ART
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eligibility. In an observational study in Kenya, Uganda and
Results Zambia, Duber et al. indicate that national HIV programmes
Overview of selected studies have implemented WHO 2013 guidelines at health facility
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level. These findings suggest that several countries have
We reviewed 16 studies from an initial collection of 293 moved quickly to align with the WHO.
articles in Google Scholar, PubMed, Cochrane, Embase and
EBSCOhost (Figure 1). We only reviewed studies that However, in a study conducted in 15 SSA countries, facilities
examined how different SSA countries adopted changes in were slow to align with the WHO’s 2006 and 2010 guidelines.
WHO and ART initiation guidelines based on CD4 They experienced delays in the actual implementation and
threshold and how the guidelines have impacted ART expanding access to ART. Burrage et al. noted that few
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programmes in SSA. The following four themes were Tanzanians were initiated on ART at CD4 counts of ≤ 500/µL
identified from the 16 papers: (1) Adoption of WHO and in 2015 despite the country’s earlier adoption of the 2013
ART initiation policy guidelines at country level in SSA, (2) WHO guidelines. As a result, only 64% of eligible PLWH
timely implementation of WHO and ART initiation policy were initiated on treatment. Stanecki et al. recorded that
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guidelines at country level, (3) barriers and facilitators to the number of PLWH eligible for ART in low- and middle-
WHO policy implementation in SSA and (4) characteristics income countries (LMICs) under the revised 2010 WHO
at country level. guidelines was 14.6 million at a time when only an estimated
10.1 million people actually received ART. As of 2015, all
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Of the 16 reviewed articles 4 (articles 4, 13, 14 and 16) 20 SSA-supported U.S. President’s Emergency Plan for AIDS
addressed all 4 themes, 8 articles addressed 3 themes (articles Relief (PEPFAR) countries had adopted the 2013 WHO
1, 2, 7, 9, 10, 11, 12 and 15) and 4 articles (articles 2, 5, 6 and 8) guidelines for ART eligibility. Nevertheless, alignment and
addressed only 2 themes. The theme of the adoption of the implementation with national guidelines took at least
WHO-ART initiation guidelines at country level was 2 years in all 20 countries. This demonstrates the failure of
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dominant in all articles. SSA countries to align and implement country guidelines
timeously with the WHO.
Theme 1: Adoption of World Health Organization
antiretroviral therapy initiation policy guidelines Theme 3: Barriers to and facilitators of antiretroviral
at country level in sub-Saharan Africa therapy initiation policy implementation
The results confirm that all the countries in SSA that are Fourteen studies examined the barriers to and facilitators of
part of this review have adopted the WHO and ART ART-initiation policy implementation in SSA. Ambia et al.
initiation guidelines since 2002. Hsieh et al. reported that reported a significant increase in ART initiations, from 42%
between July 2013 and July 2015, seven national policy to 87%, in some facilities in the urban centres of Kenya,
documents incorporating the 2013 WHO guidelines were Malawi, South Africa (SA), Tanzania, Uganda and
developed in Kenya, Malawi, Tanzania, Uganda, Zimbabwe Zimbabwe. Healthcare workers’ (HCWs) attitudes were
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and two in South Africa. This was further supported by found to be both a barrier and a facilitator of implementation
Ross et al. who found that SSA countries had some national at the facility level. Teasdale et al. reported that positive
explicit policies that targeted increasing ART access in line learning attitudes from HCWs were found to be an enabler
with the WHO 2013 guidelines on ART. In his study, Hsieh for WHO policy adoption in Rwanda. Furthermore, the
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et al. indicated that community consultations are crucial if Rwandan government’s health department assembled a task
policies are to be effectively implemented. Labhardt et al. team to ensure that the entire country was supported in the
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found that health centres in Lesotho took longer to adopt implementation of the revised guidelines. Hsieh et al.
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the new guidelines because of limited knowledge of WHO found, however, that HCWs in Malawi and Uganda were
policy changes. 21 slow to implement the 2013 WHO guidelines because their
communities ‘had not been consulted and hence lacked
Rwanda implemented the 2006, 2010, 2013 and 2015 WHO understanding’ of the guidelines. Similarly, Labhardt et al.,
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and ART initiation guidelines in a timely manner, that is, on in Lesotho found that HCWs especially in rural facilities,
an average within 6 months of international release. Part took longer to adopt and implement the 2006 and 2010
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of Rwanda’s success is attributed to the cooperation of guidelines because of limited training. There was little
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government and non-governmental service providers. support, mentoring and supervision and overall, less
http://www.sajhivmed.org.za 227 Open Access