Chan Adrienne K, Ford Deborah, Namata Harriet, Muzambi Margaret, Nkhata Misheck J, Abongomera George, Mambule Ivan, South Annabelle, Revill Paul, Grundy Caroline, Mabugu Travor, Chiwaula Levison, Cataldo Fabian, Hakim James, Seeley Janet, Kityo Cissy, Reid Andrew, Katabira Elly, Sodhi Sumeet, Gilks Charles F, Gibb Diana M
MRC Clinical Trials Unit at University College London, London, U,K.
BMC Health Serv Res. 2014 Aug 19;14:352. doi: 10.1186/1472-6963-14-352.
In sub-Saharan Africa antiretroviral therapy (ART) is being decentralized from tertiary/secondary care facilities to primary care. The Lablite project supports effective decentralization in 3 countries. It began with a cross-sectional survey to describe HIV and ART services.
81 purposively sampled health facilities in Malawi, Uganda and Zimbabwe were surveyed.
The lowest level primary health centres comprised 16/20, 21/39 and 16/22 facilities included in Malawi, Uganda and Zimbabwe respectively. In Malawi and Uganda most primary health facilities had at least 1 medical assistant/clinical officer, with average 2.5 and 4 nurses/midwives for median catchment populations of 29,275 and 9,000 respectively. Primary health facilities in Zimbabwe were run by nurses/midwives, with average 6 for a median catchment population of 8,616. All primary health facilities provided HIV testing and counselling, 50/53 (94%) cotrimoxazole preventive therapy (CPT), 52/53 (98%) prevention of mother-to-child transmission of HIV (PMTCT) and 30/53 (57%) ART management (1/30 post ART-initiation follow-up only). All secondary and tertiary-level facilities provided HIV and ART services. In total, 58/81 had ART provision. Stock-outs during the 3 months prior to survey occurred across facility levels for HIV test-kits in 55%, 26% and 9% facilities in Malawi, Uganda and Zimbabwe respectively; for CPT in 58%, 32% and 9% and for PMTCT drugs in 26%, 10% and 0% of facilities (excluding facilities where patients were referred out for either drug). Across all countries, in facilities with ART stored on-site, adult ART stock-outs were reported in 3/44 (7%) facilities compared with 10/43 (23%) facility stock-outs of paediatric ART. Laboratory services at primary health facilities were limited: CD4 was used for ART initiation in 4/9, 5/6 and 13/14 in Malawi, Uganda and Zimbabwe respectively, but frequently only in selected patients. Routine viral load monitoring was not used; 6/58 (10%) facilities with ART provision accessed centralised viral loads for selected patients.
Although coverage of HIV testing, PMTCT and cotrimoxazole prophylaxis was high in all countries, decentralization of ART services was variable and incomplete. Challenges of staffing and stock management were evident. Laboratory testing for toxicity and treatment effectiveness monitoring was not available in most primary level facilities.
在撒哈拉以南非洲地区，抗逆转录病毒疗法（ART）正从三级/二级医疗机构下放到初级保健机构。Lablite项目支持三个国家实现有效的权力下放。该项目始于一项横断面调查，以描述艾滋病毒和抗逆转录病毒疗法服务情况。
对马拉维、乌干达和津巴布韦的81家经过有目的抽样的医疗机构进行了调查。
最低级别的初级保健中心分别占马拉维、乌干达和津巴布韦纳入调查的20家、39家和22家机构中的16家、21家和16家。在马拉维和乌干达，大多数初级保健机构至少有1名医疗助理/临床干事，分别为中位服务人口29,275人和9,000人的地区平均配备2.5名和4名护士/助产士。津巴布韦的初级保健机构由护士/助产士管理，为中位服务人口8,616人的地区平均配备6名。所有初级保健机构均提供艾滋病毒检测和咨询服务，53家机构中有50家（94%）提供复方新诺明预防性治疗（CPT），53家机构中有52家（98%）提供预防母婴传播艾滋病毒（PMTCT）服务，53家机构中有30家（57%）提供抗逆转录病毒疗法管理服务（其中30家机构中只有1家在抗逆转录病毒疗法启动后进行随访）。所有二级和三级医疗机构均提供艾滋病毒和抗逆转录病毒疗法服务。总共有58/81家机构提供抗逆转录病毒疗法。在调查前的3个月内，马拉维、乌干达和津巴布韦分别有55%、26%和9%的各级医疗机构出现艾滋病毒检测试剂盒缺货情况；CPT缺货情况分别为58%、32%和9%；PMTCT药物缺货情况分别为26%、10%和0%（不包括将患者转诊至其他机构获取药物的情况）。在所有国家，在现场储存抗逆转录病毒疗法药物的机构中，报告有3/44（7%）的机构出现成人抗逆转录病毒疗法药物缺货，而儿科抗逆转录病毒疗法药物缺货的机构有10/43（23%）。初级保健机构的实验室服务有限：马拉维、乌干达和津巴布韦分别有4/9、5/6和13/14的机构在启动抗逆转录病毒疗法时使用CD4检测，但通常仅用于部分患者。未进行常规病毒载量监测；在提供抗逆转录病毒疗法的58家机构中，有6家（10%）为部分患者获取集中式病毒载量检测结果。
尽管所有国家的艾滋病毒检测覆盖率、预防母婴传播艾滋病毒和复方新诺明预防用药覆盖率都很高，但抗逆转录病毒疗法服务下放的情况各不相同且并不完善。人员配备和库存管理方面的挑战显而易见。大多数初级保健机构无法进行毒性实验室检测和治疗效果监测。
