Research Article: Evidence for scaling up HIV treatment in sub-Saharan Africa: A call for incorporating health system constraints

Date Published: February 21, 2017

Publisher: Public Library of Science

Author(s): Evelinn Mikkelsen, Jan A. C. Hontelez, Maarten P. M. Jansen, Till Bärnighausen, Katharina Hauck, Kjell A. Johansson, Gesine Meyer-Rath, Mead Over, Sake J. de Vlas, Gert J. van der Wilt, Noor Tromp, Leon Bijlmakers, Rob M. P. M. Baltussen

Abstract: Jan Hontelez and colleagues argue that the cost-effectiveness studies of HIV treatment scale-up need to include health system constraints to be more informative.

Partial Text: The scale-up of antiretroviral therapy (ART) for HIV-infected people in sub-Saharan Africa (SSA) over the past 15 years is one of the most remarkable achievements in public health. With approximately 12 million people on treatment in 2015, life expectancy on the subcontinent has vastly improved [1]. Nevertheless, ART coverage in SSA is still suboptimal, HIV incidence remains high [1], and improved survival due to ART implies ever increasing numbers of people on treatment [2]. Substantial additional resources are needed to further scale up ART, yet funding has levelled off over the recent years, increasing the need for optimizing the allocation of limited resources [3].

Supply-side constraints can be described in terms of the six health system building blocks as put forward by WHO [8]. These are (1) adequate service delivery—i.e., the availability of good, timely, and sustainable care to all patients along the full cascade of care; (2) a sufficient number of qualified health workers to provide treatment and care to all eligible patients; (3) a health information system that monitors health system performance and systematically records essential information on all patients—for example, to identify and respond to areas of underperformance or to improve re-enrolment of patients who defaulted treatment; (4) a reliable supply chain management of medical products and technologies to ensure sufficient supply of drugs and medical equipment; (5) sustainable financing to maintain care and treatment for those eligible; and (6) good governance that allows balanced, contextual decisions in allocating and managing limited resources.

Some mathematical modelling studies have explored the effects of constraints on the cost-effectiveness of ART treatment strategies in SSA. Cleary et al., Fraser et al., and Anderson et al. determined the optimal treatment strategies within the available budgets for South Africa [10], Nigeria [11], and Kenya [12], respectively. Recently, Hontelez et al. determined the cost-effectiveness of ART for all HIV-infected people within different scenarios of supply- and demand-side constraints for ten countries in SSA [2]. Although we applaud these efforts, the extent to which they incorporated constraints is limited.

CEAs of scaling up HIV treatment in SSA should be made more responsive to the needs of policy makers by taking into account the local health system context. We call for a better integration of health system constraints into CEA—by accounting for such constraints in the use of mathematical models, facilitated by a dialogue between researchers and policy makers. This will result in CEA for HIV treatment strategies that are more policy relevant, allowing policy makers in SSA countries to make feasible choices for scaling up ART. Finally, lessons learned from improved CEAs in ART scale-up can also be applied to other disease areas that face similar dilemmas, such as malaria, tuberculosis, and noncommunicable diseases, and can help researchers and policy makers to better understand the impact of integration and decentralization of services across disease areas.



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