Health Education and Research Organization, Buea, Cameroon.
Health and Human Development (2HD) Research Network, Douala, Cameroon.
Pan Afr Med J. 2022 May 5;42:6. doi: 10.11604/pamj.2022.42.6.28141. eCollection 2022.
South Africa possesses the largest anti-retroviral therapy (ART) program in the world, but the path to this record was dramatic. There is scarce literature employing a comprehensive framework to explain this achievement and inform epidemic responses. This paper applies the Advocacy Coalition Framework (ACF) to analyse the interactions among diverse actors, institutions and networks that were associated with the AIDS policy change in South Africa. Post-apartheid, HIV/AIDS and AIDS-related mortality were serious public health problems. At the time, the discernible coalitions in the HIV/AIDS policy subsystem were the pro-science coalition and AIDS dissidents. In view of the availability of compelling scientific evidence on the pathogenesis of HIV/AIDS, the clinical usefulness of ART, the availability of funding for national ART roll-out, strong global advocacy to reduce the cost of ART, all of these in an era when access to adequate HIV treatment/care was increasingly considered a human right, the environment to establish an appropriate HIV/AIDS policy for the country was conducive. However, AIDS dissidents dominated the policy agenda via their control over key institutions, the use of various dimensions of power, biasing evidence to inform policy, and promoting the activities of strong interest groups that were not in support of ART. National ART roll-out finally emerged as a political priority because of external shocks (on the AIDS policy subsystem) which disfavoured the dominant coalition. As in this important experience in the history of HIV treatment, stakeholders involved in epidemic response tend to engage in intense ideological conflicts. An adequate appraisal of the outcomes of these conflicts in terms of population health gains and adopted public health and social measures to control epidemics would require the supplementation of complex system thinking with relevant public policy concepts, notably power dimensions, governance, emergence of global health networks and evidence use in policy.
南非拥有世界上最大的抗逆转录病毒疗法（ART）项目，但达到这一纪录的道路是曲折的。几乎没有文献采用综合框架来解释这一成就并为疫情应对提供信息。本文应用倡导联盟框架（ACF）来分析与南非艾滋病政策变化相关的不同行为者、机构和网络之间的相互作用。种族隔离制度结束后，艾滋病毒/艾滋病和艾滋病相关死亡率成为严重的公共卫生问题。当时，艾滋病毒/艾滋病政策子系统中明显的联盟是支持科学的联盟和艾滋病异见人士。鉴于关于艾滋病毒/艾滋病发病机制、ART 的临床实用性、国家 ART 推广资金的可用性、全球减少 ART 成本的强烈倡导，以及在获得足够的艾滋病毒治疗/护理越来越被视为一项人权的时代，为国家制定适当的艾滋病毒/艾滋病政策创造了有利环境。然而，艾滋病异见人士通过控制关键机构、利用各种权力维度、歪曲证据以告知政策以及推动不支持 ART 的强大利益集团的活动，主导了政策议程。由于外部冲击（对艾滋病政策子系统）不利于主导联盟，国家 ART 推广最终成为一个政治优先事项。就像在艾滋病毒治疗的这一重要历史经验中一样，参与疫情应对的利益相关者往往会陷入激烈的意识形态冲突。要充分评估这些冲突对人口健康收益的影响，并采取公共卫生和社会措施来控制疫情，就需要用相关的公共政策概念（特别是权力维度、治理、全球卫生网络的出现和政策中的证据使用）来补充复杂系统思维。
