Dlamini-Simelane Thandeka, Moyer Eileen
Department of Anthropology, University of Amsterdam, Nieuwe Achtergracht 166, 1018 WV, Amsterdam, Netherlands.
, 1493 Lukhasi Street, Ext. 11 Thembelihle, P.O. 6231, Mbabane, H100, Swaziland.
BMC Health Serv Res. 2017 Jan 10;17(1):20. doi: 10.1186/s12913-016-1960-y.
In the quest to achieve early HIV treatment goals, national HIV treatment programmes dependent on international funding have been dramatically redesigned over the last 5 years. Bottlenecks in treatment provision are conceived of as health system problems to be addressed via structural and logistical fixes (routine HIV testing, point-of-care equipment, nurse-led antiretroviral treatment initiation, and patient tracking). Patient perspectives are rarely taken into account when such fixes are being considered. Patients' therapeutic experiences often remain at the periphery during the planning stage and are only considered within the context of monitoring and evaluation audits once programmes are up and running.
Ethnographic research was conducted in five clinics in Swaziland between 2012 and 2014. Participatory approaches were used to collect data; the first author trained as an HIV counsellor in order to collect observational data on the continuum of care, and conducted in-depth interviews with interlocutors involved at the different phases.
Although recently adopted global HIV strategies have proven effective in scaling up treatment in Swaziland, our research demonstrates that the effort to expand services rapidly and to meet donor targets has also undermined patients' therapeutic experiences and overtaxed health workers, both of which are counterproductive to the ultimate goal of treatment scale-up. This article provides a perspective beyond the structural elements that impede universal treatment, and explores patient views and experiences of the strategies adopted to support further treatment expansion, with a particular focus on the shifting of key care and logistical tasks to expert clients.
We argue that in the quest to achieve universal early access to treatment, both donors and states must go beyond strengthening health systems and strive to enhance the quality of patient experiences and take seriously health worker limitations.
在努力实现早期艾滋病治疗目标的过程中，依赖国际资金的国家艾滋病治疗项目在过去5年里经历了大幅重新设计。治疗服务中的瓶颈被视为需要通过结构和后勤方面的改进（常规艾滋病检测、即时护理设备、护士主导的抗逆转录病毒治疗启动以及患者追踪）来解决的卫生系统问题。在考虑这些改进措施时，很少会考虑患者的观点。在规划阶段，患者的治疗体验往往处于边缘地位，只有在项目启动并运行后，才会在监测和评估审计的背景下被考虑。
2012年至2014年期间，在斯威士兰的五家诊所开展了人种志研究。采用参与式方法收集数据；第一作者接受了艾滋病咨询师培训，以便收集关于连续护理的观察数据，并对参与不同阶段的对话者进行深入访谈。
尽管最近采用的全球艾滋病战略已证明在扩大斯威士兰的治疗规模方面是有效的，但我们的研究表明，迅速扩大服务并实现捐助方目标的努力也损害了患者的治疗体验，并使卫生工作者负担过重，这两者都不利于治疗扩大规模的最终目标。本文提供了一个超越阻碍普遍治疗的结构因素的视角，并探讨了患者对为支持进一步扩大治疗而采取的战略的看法和体验，特别关注关键护理和后勤任务向专家患者的转移。
我们认为，在努力实现普遍早期治疗的过程中，捐助方和各国政府都必须超越加强卫生系统的范畴，努力提高患者体验的质量，并认真对待卫生工作者的局限性。
