Church Kathryn, Machiyama Kazuyo, Todd Jim, Njamwea Brian, Mwangome Mary, Hosegood Vicky, Michel Janet, Oti Samuel, Nyamukapa Constance, Crampin Amelia, Amek Nyaguara, Nakigozi Gertrude, Michael Denna, Gómez-Olivé F Xavier, Nakiyingi-Miiro Jessica, Zaba Basia, Wringe Alison
Department of Population Health, London School of Hygiene & Tropical Medicine, London, UK.
African Population and Health Research Center, Nairobi, Kenya.
J Int AIDS Soc. 2017 Jan 12;20(1):21188. doi: 10.7448/IAS.20.1.21188.
Despite the rollout of antiretroviral therapy (ART), challenges remain in ensuring timely access to care and treatment for people living with HIV. As part of a multi-country study to investigate HIV mortality, we conducted health facility surveys within 10 health and demographic surveillance system sites across six countries in Eastern and Southern Africa to investigate clinic-level factors influencing (i) use of HIV testing services, (ii) use of HIV care and treatment and (iii) patient retention on ART.
Health facilities ( = 156) were sampled within 10 surveillance sites: Nairobi and Kisumu (Kenya), Karonga (Malawi), Agincourt and uMkhanyakude (South Africa), Ifakara and Kisesa (Tanzania), Kyamulibwa and Rakai (Uganda) and Manicaland (Zimbabwe). Structured questionnaires were administered to in-charge staff members of HIV testing, prevention of mother-to-child transmission (PMTCT) and ART units within the facilities. Forty-one indicators influencing uptake and patient retention along the continuum of HIV care were compared across sites using descriptive statistics.
The number of facilities surveyed ranged from six in Malawi to 36 in Zimbabwe. Eighty percent were government-run; 73% were lower-level facilities and 17% were district/referral hospitals. Client load varied widely, from less than one up to 65 HIV testing clients per provider per week. Most facilities (>80%) delivered services or interventions that would support patient retention in care such as delivering free services, offering PMTCT within antenatal care, pre-ART monitoring and adherence counselling. Many facilities under-delivered in several areas, however, such as targeted testing for high-risk groups (21%) and mobile testing (36%). There were also intra-site and inter-site differences, including in the delivery of Option B+ (ranging from 6% in Kisumu to 93% in Kyamulibwa), and nurse-led ART initiation (ranging from 50% in Kisesa to 100% in Karonga and Agincourt). Only facilities in Malawi did not require additional lab tests for ART initiation. Stock-outs of HIV test kits and antiretroviral drugs were particularly common in Tanzania.
We identified a high standard of health facility performance in delivering strategies that may support progression through the continuum of HIV care. HIV testing policy and practice was particularly weak. Inter- and intra-country differences in quality and coverage represent opportunities to improve the delivery of comprehensive services to people living with HIV.
尽管抗逆转录病毒疗法（ART）已经推广，但在确保艾滋病毒感染者及时获得护理和治疗方面仍存在挑战。作为一项多国艾滋病毒死亡率调查研究的一部分，我们在东非和南部非洲六个国家的10个卫生与人口监测系统站点内开展了医疗机构调查，以研究影响以下方面的诊所层面因素：（i）艾滋病毒检测服务的使用；（ii）艾滋病毒护理和治疗的使用；（iii）患者在抗逆转录病毒疗法上的留存率。
在10个监测站点内对156家医疗机构进行了抽样：内罗毕和基苏木（肯尼亚）、卡龙加（马拉维）、阿金库尔和姆赫尼亚库德（南非）、伊法卡拉和基塞萨（坦桑尼亚）、基亚穆利布瓦和拉凯（乌干达）以及马尼卡兰（津巴布韦）。对各医疗机构内艾滋病毒检测、预防母婴传播（PMTCT）和抗逆转录病毒疗法科室的主管工作人员进行了结构化问卷调查。使用描述性统计方法对10个监测点影响艾滋病毒护理连续过程中接受率和患者留存率的41项指标进行了比较。
接受调查的医疗机构数量从马拉维的6家到津巴布韦的36家不等。80%为政府运营；73%为基层医疗机构，17%为地区/转诊医院。每个医疗服务提供者每周的客户量差异很大，从不到1名到65名艾滋病毒检测客户不等。大多数医疗机构（>80%）提供了有助于患者持续接受护理的服务或干预措施，如提供免费服务、在产前护理中提供预防母婴传播服务、抗逆转录病毒疗法前监测和依从性咨询。然而，许多医疗机构在几个方面的服务提供不足，如针对高危人群的定向检测（21%）和流动检测（36%）。各监测点内部和之间也存在差异，包括“B+方案”的实施情况（从基苏木的6%到基亚穆利布瓦的93%）以及护士主导的抗逆转录病毒疗法启动情况（从基塞萨的50%到卡龙加和阿金库尔的100%）。只有马拉维的医疗机构在启动抗逆转录病毒疗法时不需要额外的实验室检测。艾滋病毒检测试剂盒和抗逆转录病毒药物的缺货情况在坦桑尼亚尤为常见。
我们发现医疗机构在实施可能支持艾滋病毒护理连续过程进展的策略方面表现出较高水平。艾滋病毒检测政策和实践尤其薄弱。国家间和国家内部在质量和覆盖范围上的差异为改善向艾滋病毒感染者提供综合服务提供了机会。
