An International Research
Consortium to Maximise
Benefits & Equity of HIV
Treatment & Care Systems

We are exploring several areas under this theme including the positive and negative effects HIV treatment and care scale up can have on health systems, the role of national AIDS councils in the co-ordination and monitoring of programmes and the relative merits of vertical compared to integrative programming on delivery and cost effectiveness. A key area of research is focusing on the important issue of human resources to delivering health services, decentralisation and task shifting. How have political processes influenced the distribution and allocation of human resources within the health sector? Is it possible to effectively use lower cadres of staff to deliver ARV? What role can the community play in delivery and support of ARV treatment? How does the system cope with the increasing number of patients and the different types of patients; those newly starting those who are stable and those who have failed or are suspected as failing treatment?

Theme 3 publications

Current Theme 3 Research Generated by Evidence for Action 

Integration of HIV treatment and care into the health system

LSHTM: Over the past two years a renewed emphasis on principles of primary health care (PHC) has led to a call for the greater integration of vertical disease-specific programmes and horizontal health services with the ultimate aim to strengthen health systems. This has been at least partly the result of an emerging body of evidence which has identified areas where greater coordination between, or integration of, disease-specific programmes could lead to more efficient use of resources and avoid duplication. At the 2009 G8 summit in Italy, political leaders committed themselves to strengthening health systems and GAVI, the Global Fund and the World Bank have since launched a joint funding platform for integration.Similarly, the revised PEPFAR strategy launched in December 2009 puts further emphasis on health systems’ strengthening and the integration of services. Despite the strong rhetoric and commitment, the exact strategies for achieving the integration of HIV services and PHC and health systems remain unclear. LSHTM are carrying out research to address this lack of clarity. It will add better understanding of how policymakers globally define integration and the strategies they envisage to achieve this. It is focusing on analysing the concepts of integration used by decision-makers within the four largest Global Health Initiatives (GHIs) (GFATM, World Bank, PEPFAR and GAVI) who determine the vast majority of funding for health in developing countries. Data collection is now complete, and analysis is underway. This work is funded by Evidence for Action.

Integration of HIV and Tuberculosis services

Large numbers of people in Africa and Asia are co-infected with both TB and HIV. Integrating TB and HIV services raises a number of complex challenges, making this a priority area for Evidence for Action Theme 3 research.
LSHTM and IHAA are working on a systematic review of the literature in relation to how HIV and TB services are integrated at facility level. This work is commissioned and funded by WHO, and will form a background paper to the First Symposium on Health Systems Research in October 2010.

NARI: A study is underway in India exploring the current challenges and opportunities for the integration of TB and HIV services for co-infected patients. This work, being carried out in collaboration with MAAS, will provide important insights into how clinical research on co-infection and national policies to integrate TB and HIV services are playing out in the context of local programmes, within the infrastructural, resource and staffing constraints. This work will inform the development of a larger proposal for a prospective study to examine these issues in several sites over a longer period of time to document the experiences of patients and providers over the time course of infection and care. This work is funded by an Evidence for Action SIG.

NARI are also carrying out research in Pune District exploring the criteria used by physicians for advising TB patients to test for HIV, and determine the barriers for HIV testing among TB patients. Data collection is complete and analysis is underway. This work is funded by Evidence for Action.

NARI are analysing data from a cross-sectional study of TB chemoprohylaxis in the household contacts of AFB sputum positive cases. This study is funded by Evidence for Action.

NARI are commencing work on a study of the impact of professional and lay counselling on adherence for TB treatment in clinic settings. This work is funded by Evidence for Action.

Integration of HIV treatment and prevention

Integrating prevention into HIV treatment services is critical to “positive prevention” of HIV. MRC/UVRI’s Wakiso project, described under themes 1&2 includes a component looking at whether HIV prevention can be integrated with ART delivery . The PMTCT-related studies in Kenya and Tanzania (also described under themes 1&2) also look at how HIV prevention services are integrated with HIV treatment, and the weaknesses of these links.

IHAA, Alliance Zambia, SAT Zambia and NZT+ are working on a qualitative study of adolescents growing up with HIV in Southern Africa. This includes work on the unmet SRH needs of adolescents living with HIV. Phase 1 aims to identify how to improve the SRH services available to adolescents living with HIV by exploring the gaps between access and availability of services and the specific SRH needs of adolescents. Data collection is underway, and preliminary results were presented at the International AIDS Conference in July 2010. This work is funded by ARP / SIDA.

Integration into social systems

IHAA, LSHTM & ZAMBART: The role of lay health workers (including community health workers) in HIV treatment and care was identified by Evidence for Action as one of the programme’s High Impact Topics (HITs), as lay health workers play an important role in providing HIV treatment and care, and in bridging HIV programmes and existing health and social systems. For example, a survey in South Africa found that there were over 40,000 lay health workers affiliated to government programmes in 2007, only slightly fewer than the 43,000 nurses employed by the government. A cross-sectional and observational study was carried out using qualitative and cost-analysis approaches in Zambia, looking at how the role of home-based care has changed since the introduction of ART. The results of this research have been fed back to stakeholders and policy makers in Zambia, and the results and recommendations from the study are being prepared in various formats for different audiences. The study will inform the development of standardised guidelines for training of home-based care giver volunteers. The results will also inform the revision of implementation guidelines for Home Based Care service organisations. This work was funded by an Evidence for Action SIG.

IHAA, Alliance Uganda, TASO, MRC/UVRI & LSHTM: Data collection is underway on a study looking at the role of PLHIV networks in positive and secondary prevention, impact on disclosure and ‘visibility’ of PLHIV in Uganda. It is funded by SIDA.

Project info sheets

Project info sheets are short publications intended to outline key details of specific EfA-generated projects.

Shifts in Home-based Care for People Living with HIV in the Era of ART 

‘The role of Global Health Initiatives in the implementation of antiretroviral roll-out in Copperbelt Province in Zambia’

Current Theme 3 Research Related to Evidence for Action

•    ZAMBART, together with the University of Basel, University of Bern and University of Zambia, are carrying out research on how to improve equity in access to HIV care and treatment in Zambia. It aims to investigate how structural inequalities and socio-cultural factors contribute to the underutilisation of HIV/AIDS services. Sub-studies within this project are:

o    Patient-reported barriers and drivers of adherence to ART in sub-Saharan Africa: a meta-ethnography
o    The social context, social processes and experiences related to uptake of HIV testing, treatment and disclosure of HIV sero-status in Zambia
o    Factors related to the uptake of HIV testing in sub-Saharan Africa: a meta-ethnography
o    Socio-cultural and economic factors influencing accessibility and adherence to ART in a rural setting of Zambia

This work is funded by the Swiss National Science Foundation.

•    IHAA and Alliance Myanmar are working on a project looking at private partnerships for public health (PPPH) to meet the challenge of scaling up ART in Myanmar. This is a qualitative case study that documents lessons learned from the PPPH model, assesses the partnership’s potential for scale-up, and identifies relevant recommendations for future development. A first draft of the case study has been compiled and is under review. This work was funded by Evidence for Action and USAID.