The data collected in this study provide a detailed description of the context in with HIV treatment clinic operate and characteristics of the service delivery models they have adopted. Over recent year the sites included in the study have scaled up rapidly with the influx of resources and technical support through PEPFAR and other partners, providing complex health services to progressively expanding patient cohorts.
Nevertheless, major barriers must be overcome to achieve universal access to ART. One of the main constraints is a shortage of health workers. The service delivery models described in this study placed emphasis on physicians providing initial ART assessments and follow-up. As countries decide to add new points of service or increase numbers of patients at existing sites, or both, reliance on a physician-driven model may be unfeasible. In this situation, task shifting—the reallocation of clinical tasks between cadres—is a potential alternative to conventional service delivery models and may provide the best approach for increasing human resources quickly enough to match the continuing scale-up of treatment programs.7
Of the study sites, less than one-third performed viral load testing. Current World Health Organization (WHO) guidelines in resource-limited settings recommend the use of CD4 counts to monitor therapy in programs where viral load testing is not available.8
Not monitoring viral loads raises concerns that CD4 counts can mislead clinicians into changing ARV drug regimens too early (CD4 count decline with suppressed viral load) or too late (CD4 count stable with persistent viremia).9
The optimal strategy for monitoring patients receiving ART needs further study, but our evaluation pointed out the variability in this clinical practice.
Our findings showed variations at sites in terms of the supportive care provided to patients. Certain key services—such as cotrimoxazole prophylaxis—had been adopted at all but one point of service. Other services are provided less commonly. Programs differed in their approaches on the ability to treat TB onsite and the ability to track patients in the community to support adherence and retention. While there are few data to support improved outcomes resulting from colocated TB and HIV services, it is likely that collocation would reduce patient attrition between different components of care. Slightly more than one-half of the sites had community-based activities to support ART adherence. The incremental cost of community-based activities needs to be evaluated to determine if the activities improve patient adherence, increase retention of ART patients, and ultimately improve outcomes.
When examining the ARV drugs that are being used across sites, the patterns clearly reflect the WHO guidelines for ART in resource-limited settings at the time of the study.10
Most patients were receiving a nucleoside reverse transcriptase inhibitor (NRTI) backbone of stavudine (d4T) or zidovudine (AZT) in combination with lamivudine (3TC). Only a small percentage of patients were receiving tenofovir (TNF). Most NRTI backbones were complemented by an NNRTI, with nevirapine (NVP) being the most common. Protease inhibitors, which in resource-limited settings are often reserved for second-line therapy, were used in only a small number of patients.
The study has limitations due the nature of its design. Because the sites were selected purposively from a subsample of countries, the sampled sites may not represent care and treatment services across the PEPFAR initiative. In addition, a subset of the clinical descriptors—such as staffing roles and clinical protocols—were captured only for the last 6-month periods and so we were unable to assess the trends in these characteristics as the treatment programs matured.
These data, collected in 2006–2007 represent a snap-shot of the initial phase of treatment program scale-up and maturation, allowing us to better understand the package of services provided at HIV treatment sites and the service delivery models used to provide them. To be successful, the ongoing efforts to increase ART access must overcome constraints in infrastructure and human and financial resources. The present study revealed the heterogeneity of program designs, highlighting the opportunity for further operational research to identify and promote best practices. Ultimately, through refining the package of services that patients receive and the methods used to provide them, strategies can be identified that maximize the effectiveness and efficiency of treatment programs, and in this way promote the universal access goals for treatment programs.