Wide variation in national HIV policies associated with HIV testing and treatment across six African countries

A comparative analysis of national HIV policies in six African countries with generalized epidemics.

Church K, Kiweewa F, Dasgupta A, Mwangome M, Mpandaguta E, Gomez-Olive FX, Oti S, Todd J, Wringe A, Geubbels E, Crampin A, Nakiyingi-Miiro J, Hayashi C, Njage M, Wagner RG, Ario AR, Makombe SD, Mugurungi O, Zaba B. Bull World Health Organ. 2015 Jul 1;93(7):457-67. doi: 10.2471/BLT.14.147215. Epub 2015 Apr 28.

Objective: To compare national human immunodeficiency virus (HIV) policies influencing access to HIV testing and treatment services in six sub-Saharan African countries.

Methods: We reviewed HIV policies as part of a multi-country study on adult mortality in sub-Saharan Africa. A policy extraction tool was developed and used to review national HIV policy documents and guidelines published in Kenya, Malawi, South Africa, Uganda, the United Republic of Tanzania and Zimbabwe between 2003 and 2013. Key informant interviews helped to fill gaps in findings. National policies were categorized according to whether they explicitly or implicitly adhered to 54 policy indicators, identified through literature and expert reviews. We also compared the national policies with World Health Organization (WHO) guidance.

Findings: There was wide variation in policies between countries; each country was progressive in some areas and not in others. Malawi was particularly advanced in promoting rapid initiation of antiretroviral therapy. However, no country had a consistently enabling policy context expected to increase access to care and prevent attrition. Countries went beyond WHO guidance in certain areas and key informants reported that practice often surpassed policy.

Conclusion: Evaluating the impact of policy differences on access to care and health outcomes among people living with HIV is challenging. Certain policies will exert more influence than others and official policies are not always implemented. Future research should assess the extent of policy implementation and link these findings with HIV outcomes.

Abstract [1]  Full-text [free] access [2]

Editor’s notes: Despite evidence on reduction in HIV attributable mortality, concerns still remain on the high attrition rates across the diagnosis-to-treatment cascade. This paper uses a comparative policy analysis to track differences in national HIV policy responses to the HIV epidemic. The methodology used is notable as it offers a helpful conceptual framework for the HIV policy and service factors influencing specific differences in HIV-associated adult mortality across the diagnosis-to-treatment cascade.

The range of policies between countries was unexpected, given the explanation offered by the authors that African countries tend to adopt standards and guidance from WHO. Furthermore, while countries showed progressive elements, no country had the comprehensive policy context necessary for a decisive impact on service access. Important differences were also noted in the influential weight given to some policies, in the timing of policy implementation in some indicators, and in whether WHO national standards were or were not adopted by countries.

These findings are particularly useful in better understanding the incentives and barriers to accessing antiretroviral therapy in different contexts.

HIV testing [5], National responses [6]
Africa [7]
Kenya [8], Malawi [9], South Africa [10], Uganda [11], United Republic of Tanzania [12], Zimbabwe [13]
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