Page 236 - HIVMED_v21_i1.indb

Page 9 of 11 Review Article

13
knowledge of health policy. The trainings were conducted in Zimbabwe. Walsh et al. reported a similar challenge in
24
the cities. Travel from remote areas proved a challenge as Swaziland. This review has highlighted delays in aligning
facilities would have been left without clinical staff. The and implementing the WHO-ART-initiation guidelines
authors make the point that the government did not make in 20 SSA countries. This suggests a need for greater
14
sufficient effort to deploy trainers in the remote areas where guidance with regard to strategy and implementation in the
more people needed the services. communities of SSA.

The cost-effectiveness articles namely 8, 9, 10 and 11, in Discussion
Table 1, indicate that economic constraints hindered various
countries from implementing guidelines timeously. An This review provides detailed information regarding WHO
Ethiopian study by Konings et al., revealed major financial and ART initiation guidelines on CD4 count threshold
constraints for the state even before ART services could be changes and adoption of the guidelines in SSA. There were
expanded as per the 2013 WHO guidelines. The government some variations in study designs, however, all the articles
continued implementing the 2006 ART guidelines for more focused on CD4 ART-initiation changes in the WHO
than a year after the 2010 guidelines were released because guidelines. The findings indicate that delays in adoption and
their financial capacity could not absorb the increased implementation were frequent and widespread throughout
demand. Hontelez et al., in rural SA, reported that changes SSA. We employed a thematic analysis and identified four
23
to the 2010 WHO guidelines led to an increase in programme crucial themes that were in all the articles. Several barriers to
costs requiring the SA government to add at least ZAR 3 implementing the guidelines were identified. These include
billion to the healthcare budget to allow for an increase in costs related to providing ART to eligible individuals, the
personnel and medication. 18 shortage of staff and drugs in healthcare facilities and limited
training of staff when guidelines were changed.
Most facilities in SSA failed to fully implement the policy
guidelines on time because of limited ARV-stock. In a study Our findings are consistent with those of Pell et al., who
13
from Swaziland, ARV-shortages delayed the implementation reported that the implementation of the 2015 guidelines took
of the 2015 WHO guidelines on UTT. The available stock > 12 months to be adopted in all SSA countries after their
was not sufficient for those already on treatment. Walensky official release. 1
24
et al. reported that delays in obtaining baseline blood-test
results delayed the SA-implementation of ART-guidelines in Mikkelsen et al. noted that in an effort to contain the
2010. The 2-week turnaround time resulted in people not demand for ART, most African countries were forced to defer
26
returning for results. Laboratory services were not readily treatment-initiation to those eligible PLWH who were well.
accessible in rural areas and specimen-transport-delays Whilst policy is well intentioned, it is informed only by
resulted in the samples clotting and being discarded. epidemiological data. The state of the healthcare system and
5
Staff shortages in Ethiopia were identified as a barrier to sociocultural factors are critical for controlling and ending
implementation of the 2010 ART guidelines. In some the epidemic. Our analysis of the financial, infrastructural,
facilities, there was neither a doctor nor a qualified nurse human resources for health and governance landscape in
trained to initiate ART and PLWH had to be referred to SSA, the feasibility associated with costs of implementing
distant hospitals. 23 a UTT programme indicates health systems and societal
perceptions related shortcomings. Although with clinical
Theme 4: Characteristics at country level benefits, increasing the CD4 threshold has implications that
reverberate across sectors: it affects budgets, infrastructure
World Health Organization guidelines are based on the best
available scientific evidence and are directed to the ART- and human resources.
needs of LMICs. International guidelines unfortunately
cannot speak to the individual economic and social realities of The WHO-ART guidelines are crafted by an international
individual SSA countries. Of the 20 countries addressed in committee of experts drawn from rich and poor nations
this review, there are nonetheless considerable similarities whose mandate is to provide the world’s low- and middle-
such as strained healthcare systems, structural and operational income countries (LMICs) with affordable high-quality ART
barriers and the need of cost-cutting measures to support guidelines. Historically, ART-guideline development in high-
healthcare systems. With the largest ART-programme on the income countries is independent of the WHO and takes a
continent, SA also carries the largest ART-related financial more local character, for example, the International AIDS
7
burden. Nigeria and Uganda have similar challenges. Society (IAS)-USA division, the Southern African HIV
8
Funding-cuts from international donors exacerbate these Clinicians Society, the European AIDS Clinical Society
12
challenges. Burrage et al. had noted that despite the (EACS), the British HIV Association and the ASIA-Pacific
expanded ART eligibility criteria, 20 PEPFAR-supported SSA HIV Society, etc. Liaison between the WHO and these
countries with a high HIV-burden, had funding cuts before regional societies and associations is constant. WHO
the release of the 2013 guidelines. This created continuing guidelines committee members are also members of their
regional gaps in ART coverage. Drug-stock outs have been national HIV-agencies. International ART guidelines are
14
reported from Kenya, Malawi, SA, Tanzania, Uganda and almost never produced in isolation.

http://www.sajhivmed.org.za 228 Open Access