Department for Infectious Disease Epidemiology, Imperial College London, Norfolk Place, London, W2 1PG, United Kingdom.
Biomedical Research and Training Institute, Harare, Zimbabwe.
Health Res Policy Syst. 2018 Sep 21;16(1):92. doi: 10.1186/s12961-018-0358-1.
BACKGROUND: In recent years, WHO has made major changes to its guidance on the provision of HIV care and treatment services. We conducted a longitudinal study from 2013 to 2015 to establish how these changes have been translated into national policy in Zimbabwe and to measure progress in implementation within local health facilities. METHODS: National HIV programme policy guidelines published between 2003 and 2013 (n = 9) and 2014 and 2015 (n = 5) were reviewed to assess adoption of WHO recommendations on HIV testing services, prevention of mother-to-child transmission (PMTCT) of HIV, and provision of antiretroviral therapy (ART). Changes in local implementation of these policies over time were measured in two rounds of a survey conducted at 36 health facilities in Eastern Zimbabwe in 2013 and 2015. RESULTS: High levels of adoption of WHO guidance into national policy were recorded, including adoption of new recommendations made in 2013-2015 to introduce PMTCT Option B+ and to increase the threshold for ART initiation from CD4 ≤ 350 cells/mm to ≤ 500 cells/mm. New strategies to implement national HIV policies were introduced such as the decentralisation of ART services from hospitals to clinics and task-shifting of care from doctors to nurses. The proportions of health facilities offering free HIV testing and counselling, PMTCT (including Option B+) and ART services increased substantially from 2013 to 2015, despite reductions in numbers of health workers. Provision of provider-initiated HIV testing remained consistently high. At least one test-kit stock-out in the prior year was reported in most facilities (2013: 69%; 2015: 61%; p = 0.44). Stock-outs of first-line ART and prophylactic drugs for opportunistic infections remained low. Repeat testing for HIV-negative individuals within 3 months decreased (2013: 97%; 2015: 72%; p = 0.01). Laboratory testing remained low across both survey rounds, despite policy and operational guidelines to expand coverage of diagnostic services. CONCLUSIONS: Good progress has been made in implementing international guidance on HIV service delivery in Zimbabwe. Further novel implementation strategies may be needed to achieve the latest targets for universal ART eligibility.
背景：近年来，世界卫生组织（WHO）对其提供艾滋病毒护理和治疗服务的指导意见进行了重大修改。我们进行了一项纵向研究，时间跨度为 2013 年至 2015 年，旨在确定这些变化如何转化为津巴布韦的国家政策，并衡量当地卫生机构内实施进展。
方法：审查了 2003 年至 2013 年（n=9）和 2014 年至 2015 年（n=5）发布的国家艾滋病毒规划政策准则，以评估对世卫组织关于艾滋病毒检测服务、预防艾滋病毒母婴传播（PMTCT）和提供抗逆转录病毒治疗（ART）建议的采纳情况。在 2013 年和 2015 年，在津巴布韦东部的 36 个卫生设施进行了两轮调查，以衡量这些政策在当地实施情况的变化。
结果：记录了世卫组织指导意见在国家政策中得到高度采纳，包括在 2013-2015 年期间采纳了新的建议，引入了 PMTCT 选项 B+，并将开始 ART 的 CD4 细胞计数阈值从 ≤350 个细胞/mm 提高到 ≤500 个细胞/mm。还引入了实施国家艾滋病毒政策的新战略，例如将 ART 服务从医院下放到诊所，并将护理工作从医生转移到护士。尽管卫生工作者人数减少，但提供免费艾滋病毒检测和咨询、PMTCT（包括选项 B+）和 ART 服务的卫生设施比例从 2013 年到 2015 年大幅增加。提供者启动的艾滋病毒检测仍然很高。在大多数设施中，在前一年报告了至少一种试剂盒缺货情况（2013 年：69%；2015 年：61%；p=0.44）。一线抗逆转录病毒药物和预防机会性感染的药物缺货情况仍然较低。重复检测 HIV 阴性个体的比例从 3 个月内（2013 年：97%；2015 年：72%；p=0.01）下降。尽管有政策和业务指南来扩大诊断服务覆盖范围，但实验室检测仍在两轮调查中都很低。
结论：在津巴布韦实施艾滋病毒服务提供方面的国际指导方面取得了良好进展。可能需要进一步创新实施战略，以实现普及 ART 资格的最新目标。
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