Identifying gaps in HIV service delivery across the diagnosis-to-treatment cascade: findings from health facility surveys in six sub-Saharan countries.
Identifying gaps in HIV service delivery across the diagnosis-to-treatment cascade: findings from health facility surveys in six sub-Saharan countries.
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DOI：
10.7448/ias.20.1.21188
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发表时间：
2017-01-12
影响因子：
6
通讯作者：
Wringe A
中科院分区：
文献类型：
--
作者：
Church K;Machiyama K;Todd J;Njamwea B;Mwangome M;Hosegood V;Michel J;Oti S;Nyamukapa C;Crampin A;Amek N;Nakigozi G;Michael D;Gómez-Olivé FX;Nakiyingi-Miiro J;Zaba B;Wringe A
导言：尽管推出了抗逆转录病毒疗法（ART），但在确保艾滋病毒感染者及时获得护理和治疗方面仍然存在挑战。作为调查艾滋病毒死亡率的多国研究的一部分，我们在东部和南部非洲6个国家的10个卫生和人口监测系统站点进行了卫生设施调查，以调查影响(i)使用艾滋病毒检测服务，（ii）使用艾滋病毒护理和治疗以及（iii）患者保留抗逆转录病毒治疗的临床水平因素。方法：在内罗毕和基苏木（肯尼亚）、卡隆加（马拉维）、阿金库尔和乌姆汉亚库德（南非）、伊法卡拉和基萨萨（坦桑尼亚）、基亚穆里布瓦和拉凯（乌干达）以及曼尼兰（津巴布韦）等10个监测点对卫生设施（156例）进行抽样调查。对设施内负责艾滋病毒检测、预防母婴传播（PMTCT）和抗逆转录病毒治疗单位的工作人员进行了结构化问卷调查。使用描述性统计比较了不同地点的41个影响艾滋病毒治疗连续体吸收和患者保留的指标。结果：调查的设施数量从马拉维的6个到津巴布韦的36个不等。80%是政府办的；73%是基层医院，17%是区/转诊医院。客户的工作量差别很大，从每个服务提供者每周不到一个到65个艾滋病毒检测客户不等。大多数机构（80%）提供的服务或干预措施将支持患者继续接受治疗，例如提供免费服务，在产前保健中提供预防母婴传播，抗逆转录病毒治疗前监测和依从性咨询。然而，许多设施在一些领域的服务不足，例如针对高危人群的定向检测（21%）和移动检测（36%）。站点内和站点间也存在差异，包括提供备选方案B+（基苏木为6%，基亚穆利布瓦为93%）和护士主导的抗逆转录病毒治疗启动（基萨萨为50%，卡隆加和阿金库尔为100%）。只有马拉维的设施不需要为启动抗逆转录病毒治疗进行额外的实验室检测。艾滋病毒检测试剂盒和抗逆转录病毒药物缺货在坦桑尼亚尤为普遍。结论：我们确定了高标准的卫生设施在提供战略方面的表现，这些战略可能通过持续的艾滋病毒护理来支持进展。艾滋病毒检测政策和做法尤其薄弱。国家间和国家内部在质量和覆盖面方面的差异代表着改善向艾滋病毒感染者提供全面服务的机会。
Introduction: 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. Methods: Health facilities (n = 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. Results: 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. Conclusions: 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.