Research Article: Rapid Scale-Up of Antiretroviral Treatment in Ethiopia: Successes and System-Wide Effects

Date Published: April 28, 2009

Publisher: Public Library of Science

Author(s): Yibeltal Assefa, Degu Jerene, Sileshi Lulseged, Gorik Ooms, Wim Van Damme

Abstract: Yibeltal Assefa and colleagues describe the successes and challenges of the scale-up of antiretroviral treatment across Ethiopia, including its impact on other health programs and the country’s human resources for health.

Partial Text: The provision of antiretroviral treatment (ART) has decreased morbidity and mortality in people living with HIV/AIDS [1],[2]. However, introducing ART to sub-Saharan Africa was a topic of hot debate just a few years ago. Concerns about adherence and subsequent development of drug resistance, poor infrastructure, logistic and human capacity, and cost-effectiveness were the major issues [3]. Once pilot projects indicated the feasibility of ART delivery in resource-limited settings, the World Health Organization catalyzed the global effort by declaring lack of access to effective HIV treatment a global emergency. This resulted in the “3 by 5” initiative, which aimed to provide 3 million people in developing countries with ART by the end of 2005 [4]—a 10-fold increase in two years, as in 2003, only 100,000 people living with HIV/AIDS in developing countries were able to access ART [4].

According to the most recent estimates, about 1 million people (2.2% of the adult population) were living with HIV in Ethiopia in 2008. In the same year, approximately 290,000 people needed ART [12]. To respond to the treatment needs of people living with HIV/AIDS, the National Antiretroviral Drugs Policy was developed in 2002, and the first treatment guideline for adults and adolescents was issued in 2003 and revised in 2007 [13]. A fee-based ART program was officially started in 2003. Moreover, a number of initiatives have been undertaken to expand the availability of ART in Ethiopia, including those by the Global Fund, PEPFAR, the Ethiopian North American Health Professionals Association, the Clinton Foundation, and the Ethiopian Red Cross Society [5]. As a result, a free ART program was launched in early 2005. Under the guidance of the strategic plan for the multi-sectoral response, 2004–2008 [14] and the road map for accelerated access to ART, 2004–2006 and 2007–2008/10 [15],[16], the ART roll-out plan has been implemented. Consequently, ART services have been decentralized and have been available in both health centers and hospitals since August 2006 [17],[18].

The number of patients ever started on ART increased from 900 at the beginning of 2005 to more than 150,000 by June 2008 (Figure 1); and the number of patients enrolled for ART has also increased from 2,700 to 5,000 per month. The proportion of women and children, out of the total number of patients who received ART, increased from 25% in 2005 to 55% in 2008; the proportion of patients receiving ART outside Addis Ababa increased from 35% in 2005 to 75% in 2008 [18]. This has happened following the establishment of the decentralized and free ART program in the country since 2005. The number of clients receiving HIV counseling and testing services has also increased considerably, from 448,000 (between mid-2004 and mid-2005) to more than 4.5 million (between mid-2007 and mid-2008) [18].

The trend among physicians seems alarming as the number of physicians in the public services appears to have decreased from 1,613 in 2003 to 1,037 in 2007, while the number in the private for-profit and NGO (nongovernmental organization) sectors has increased from 419 in 2003 to 769 in 2007 [21]. It has been highly worrying that the “internal brain-drain” is depleting HRH in the public sector. Key informants confirmed that many highly skilled physicians have left the public sector to work with NGOs, mainly AIDS programs, in training and mentorship activities for health workers in the public sector. Therefore, these physicians working in the AIDS-related NGOs have left the public sector in the sense that they are no longer paid by the government; otherwise, they are still supporting the public sector, but exclusively for AIDS programs. On the other hand, the number of mid-and low-level health workers such as health officers and health extension workers has been increasing. The number of health officers increased from 631 in 2003 to1,151 in 2007; the training of health extension workers started in 2003 and increased to 17,653 in 2007 [21].

Access to ART has dramatically increased in Ethiopia over the last three years; this has been accompanied by an equally dramatic increase in the number of people tested for HIV, which has in turn enhanced access to care and treatment services. However, the number of patients dropping out of care is a concern that needs to be addressed with strategic interventions, including the chronic care model that links health care delivery with community- and home-based interventions.



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