Human resources for treating HIV/AIDS:: Needs, capacities, and gaps
Human resources for treating HIV/AIDS:: Needs, capacities, and gaps
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DOI：
10.1089/apc.2007.0193
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发表时间：
2007-11-01
影响因子：
4.9
通讯作者：
Humair, Salal
中科院分区：
文献类型：
--
作者：
Barnighausen, Till;Bloom, David E.;Humair, Salal
尽管最近国际社会努力扩大抗逆转录病毒治疗（ART）的规模，但在低收入和中等收入国家，有500多万需要抗逆转录病毒治疗的人没有得到治疗，治疗艾滋病毒/艾滋病的人力资源有限是实现抗逆转录病毒治疗普及的主要制约因素之一。我们对所需和可用的HRHA之间的差距进行建模，以量化到2017年实现和维持普遍ART覆盖的挑战。我们使用最近发表的ART覆盖率、HIV发病率、卫生工作者移民率、需要ART的人的死亡率以及治疗1000名ART患者所需的HRHA数量的估计值（基于2006年的回顾性研究）来估计LMIC的HRHA差距。我们使用一个简单的离散时间模型预测了10年（2017年）的HRHA缺口，其中卫生工作者库通过教育得到补充，通过移民/死亡而耗尽;需要ART的人群补充了给定的艾滋病毒发病率;接受治疗的人群的生存率更高。我们分析了不同假设的影响HRHA流入和流出和艾滋病毒大流行的演变在三个不同的区域基础情况下（撒哈拉以南非洲，非撒哈拉以南非洲LMIC和南非）。目前，LMIC的ART覆盖率约为28%-32%，在其他条件相同的情况下，到2017年，HRHA生产率将下降到16%-19%。一个简单的模型，忽略了增加生存概率所造成的抗逆转录病毒治疗，表明大约目前的数量HRHA在抗逆转录病毒治疗服务需要增加，每年为未来十年，以实现普遍覆盖到2017年。在一个考虑到接受治疗的患者生存率增加的模型中，结果因地区而异;撒哈拉以南非洲需要两倍，非撒哈拉以南非洲LMIC需要1.5倍，南非需要在未来10年内每年增加各自目前HRHA人口的三倍以上，以实现到2017年的全民覆盖。即使到2017年实现，维持全民覆盖也需要进一步增加HRHA，直到系统达到稳定状态。抗逆转录病毒治疗的覆盖率对HRHA的流入和流出很敏感。我们的模型量化了缩小LMIC中HRHA差距的挑战。它表明，战略，以实现普遍的抗逆转录病毒治疗的覆盖率必须考虑到反馈，由于较高的生存概率的人接受ART.It表明，普遍的抗逆转录病毒治疗的覆盖率是不太可能实现和持续增加HRHA流入单独，但将需要减少HRHA流出，大幅降低艾滋病毒的发病率，或在性质或组织的护理变化。减少HRHA移民外流的手段包括提供保健教育奖学金，条件是接受者在抗逆转录病毒疗法需求高的国家提供抗逆转录病毒疗法若干年，培训没有国际移动的保健工作者，或改变接收发展中国家保健工作者的国家的招聘政策。有效的组织变革包括减少治疗固定数量患者所需的HRHA数量。鉴于即使是乐观的假设也表明，在未来几十年中，ART服务将需要大量的卫生工作者，政策制定者必须确保ART计划的工作人员流动不会危及其他重要卫生服务的提供。
Despite recent international efforts to scale-up antiretroviral treatment (ART), more than 5 million people needing ART in low- and middle-income countries (LMIC) do not receive it. Limited human resources to treat HIV/AIDS (HRHA) are one of the main constraints to achieving universal ART coverage. We model the gap between needed and available HRHA to quantify the challenge of achieving and sustaining universal ART coverage by 2017. We estimate the HRHA gap in LMIC using recently published estimates of ART coverage, HIV incidence, health-worker emigration rates, mortality rates of people needing ART, and numbers of HRHA needed to treat 1000 ART patients (based on review studies, 2006). We project the HRHA gap in 10 years (2017) using a simple discrete-time model with a health worker pool replenished through education and depleted through emigration/death; a population needing ART replenished with a given HIV incidence rate; and higher survival rates for treated populations. We analyze the effects of varying assumptions about HRHA inflows and outflows and the evolution of the HIV pandemic in three different regional base cases (sub-Saharan Africa, non-sub-Saharan African LMIC, and South Africa). Current ART coverage for LMIC is around 28%-32% and, other things equal, will drop to 16%-19% by 2017 with constant current HRHA production rates. A naive model, ignoring the increased survival probability resulting from ART, suggests that approximately the current number of HRHA in ART services needs to be added every year for the next ten years to achieve universal coverage by 2017. In a model accounting for increased survival of treated patients, outcomes vary by region; sub-Saharan Africa requires two times, non-sub-Saharan African LMIC require 1.5 times and South Africa requires more than three times their respective current HRHA population to be added every year for the next 10 years to achieve universal coverage by 2017. Even if achieved by 2017, sustaining universal coverage requires further HRHA increases until the system reaches steady state. ART coverage is sensitive to HRHA inflow and emigration. Our model quantifies the challenge of closing the HRHA gap in LMIC. It shows that strategies to achieve universal ART coverage must account for feedback due to higher survival probabilities of people receiving ART. It suggests that universal ART coverage is unlikely to be achieved and sustained with increased HRHA inflows alone, but will require decreased HRHA outflows, substantially reduced HIV incidence, or changes in the nature or organization of care. Means to decrease HRHA emigration outflows include scholarships for healthcare education that are conditional on the recipient delivering ART in a country with high ART need for a number of years, training health workers who are not internationally mobile, or changing recruitment policies in countries receiving health workers from the developing world. Effective organizational changes include those that reduce the number of HRHA required to treat a fixed number of patients. Given the large number of health workers that even optimistic assumptions suggest will be needed in ART services in the coming decades, policymakers must ensure that the flow of workers into ART programs does not jeopardize the provision of other important health services.