A three-tier framework for monitoring antiretroviral therapy in high HIV burden settings
A three-tier framework for monitoring antiretroviral therapy in high HIV burden settings
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DOI：
10.7448/ias.17.1.18908
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发表时间：
2014-04-28
影响因子：
6
通讯作者：
Boulle, Andrew
中科院分区：
文献类型：
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作者：
Osler, Meg;Hilderbrand, Katherine;Boulle, Andrew
在低收入和中等收入国家提供抗逆转录病毒疗法是一项规模空前的慢性病干预措施，是高负担国家卫生系统面临的主要挑战，其中许多国家是世界上最贫穷的国家。大量的外部投资，加上服务演变以适应不断变化的需求的要求，包括不断转向早期抗逆转录病毒疗法的启动，使得成果监测和报告尤为重要。然而，人们日益关切的是，许多高负担国家无法报告接受不同时间护理的病人的结果，甚至无法报告在某一特定时间点接受护理的病人人数。在许多情况下，各国只能报告开始接受抗逆转录病毒治疗的患者人数。尽管纸质登记系统面临越来越大的压力，但在许多情况下，从纸质直接演变为复杂的电子病历解决方案是不可行的。实施桥接解决方案，例如简单的离线电子版纸质登记册，可能是一种务实的替代办法。本文根据南非西开普省实施这一系统的经验，介绍并建议在低收入和中等收入国家采用三级监测方法。三级办法使卫生部能够在提供抗逆转录病毒疗法服务的每个设施战略性地实施其中一级。每一级都编制国家要求的相同的每月登记报告和季度群组报告，以便将这三级的产出汇总到卫生系统任何一级的单一数据库中。层的选择基于实现时的环境和资源。随着资源和基础设施的改善，更多的设施将过渡到下一个最高和技术更先进的层次。在国家一级对抗逆转录病毒治疗前的健康、抗逆转录病毒治疗、结核病和妇幼保健服务实施三级监测系统，可以是一种有效的办法，在扩大电子监测解决方案的过程中，确保全系统的协调一致和对服务的准确监测，包括长期保持护理。
The provision of antiretroviral therapy (ART) in low and middle-income countries is a chronic disease intervention of unprecedented magnitude and is the dominant health systems challenge for high-burden countries, many of which rank among the poorest in the world. Substantial external investment, together with the requirement for service evolution to adapt to changing needs, including the constant shift to earlier ART initiation, makes outcome monitoring and reporting particularly important. However, there is growing concern at the inability of many high-burden countries to report on the outcomes of patients who have been in care for various durations, or even the number of patients in care at a particular point in time. In many instances, countries can only report on the number of patients ever started on ART. Despite paper register systems coming under increasing strain, the evolution from paper directly to complex electronic medical record solutions is not viable in many contexts. Implementing a bridging solution, such as a simple offline electronic version of the paper register, can be a pragmatic alternative. This paper describes and recommends a three-tiered monitoring approach in low-and middle-income countries based on the experience implementing such a system in the Western Cape province of South Africa. A three-tier approach allows Ministries of Health to strategically implement one of the tiers in each facility offering ART services. Each tier produces the same nationally required monthly enrolment and quarterly cohort reports so that outputs from the three tiers can be aggregated into a single database at any level of the health system. The choice of tier is based on context and resources at the time of implementation. As resources and infrastructure improve, more facilities will transition to the next highest and more technologically sophisticated tier. Implementing a three-tier monitoring system at country level for pre-antiretroviral wellness, ART, tuberculosis and mother and child health services can be an efficient approach to ensuring system-wide harmonization and accurate monitoring of services, including long term retention in care, during the scale-up of electronic monitoring solutions.