London School of Hygiene & Tropical Medicine, UK.
Health Policy Plan. 2010 Sep;25(5):352-62. doi: 10.1093/heapol/czq005. Epub 2010 Feb 8.
Home-based care (HBC) programmes in low- and middle-income countries have evolved over the course of the past two decades in response to the HIV epidemic and wider availability of antiretroviral therapy (ART). Evidence is emerging from small-scale and well-resourced studies that ART delivery can be effectively incorporated within HBC programmes. However, before this approach can be expanded, it is necessary to consider the lessons learned from implementing routine HBC programmes and to assess what conditions are required for their roll-out in the context of ART provision. In this paper, we review the literature on existing HBC programmes and consider the arguments for their expansion in the context of scaling up ART delivery. We develop a framework that draws on the underlying rationale for HBC and incorporates lessons learned from community health worker programmes. We then apply this framework to assess whether the necessary conditions are in place to effectively scale up HBC programmes in the ART era. We show that the most effective HBC programmes incorporate ongoing support, training and remuneration for their workers; are integrated into existing health systems; and involve local communities from the outset in programme planning and delivery. Although considerable commitment has so far been demonstrated to delivering comprehensive HBC programmes, their effectiveness is often hindered by weak linkages with other HIV services. Top-down donor policies and a lack of sustainable and consistent funding strategies represent a formidable threat to these programmes in the long term. The benefits of HBC programmes that incorporate ART care are unlikely to be replicated on a larger scale unless donors and policymakers address issues related to human resources, health service linkages and community preparedness. Innovative and sustainable funding policies are needed to support HBC programmes if they are to effectively complement national ART programmes in the long term.
家庭为基础的护理（HBC）计划在过去二十年中，针对艾滋病毒流行和更广泛的抗逆转录病毒治疗（ART）的出现而发展起来。小规模和资源充足的研究正在出现证据表明，ART 可以有效地纳入 HBC 计划中。然而，在扩大这种方法之前，有必要考虑在实施常规 HBC 计划中吸取的经验教训，并评估在提供 ART 的背景下推出这些计划所需的条件。在本文中，我们回顾了现有的 HBC 计划文献，并考虑了在扩大 ART 供应规模的背景下扩大这些计划的理由。我们制定了一个框架，该框架借鉴了 HBC 的基本原理，并纳入了社区卫生工作者计划中吸取的经验教训。然后，我们应用该框架来评估在 ART 时代是否具备有效扩大 HBC 计划的必要条件。我们表明，最有效的 HBC 计划为其工作人员提供持续的支持、培训和报酬；融入现有的卫生系统；并从一开始就让当地社区参与到项目规划和实施中。尽管到目前为止，为提供全面的 HBC 计划做出了相当大的承诺，但由于与其他 HIV 服务的联系薄弱，这些计划的有效性往往受到阻碍。自上而下的捐助政策和缺乏可持续和一致的供资战略是这些计划的长期严峻威胁。除非捐助者和决策者解决与人力资源、卫生服务联系和社区准备有关的问题，否则将 ART 护理纳入 HBC 计划的好处不太可能在更大规模上得到复制。如果 HBC 计划要长期有效地补充国家 ART 计划，则需要创新和可持续的供资政策来支持这些计划。
