Understanding gaps in the HIV treatment cascade in eleven West African countries: Findings from a regional community treatment observatory
Year: 2019 Working paper number: 441 Author: Oberth,Baptiste,Jallow,Manouan,Garcia,Traore,Murara and Boka Unit: CSSR Abstract:
In West and Central Africa, 48% of people living with HIV are aware of their status, 40% are accessing antiretroviral therapy (ART), and 29% are virally suppressed. Progress towards universal treatment access is stymied by a range of diverse challenges, including drug stockouts, weak health systems, human rights barriers, and low quality of care. In February 2017, the International Treatment Preparedness Coalition (ITPC) established a regional community treatment observatory in West Africa to increase accountability for the UNAIDS 90-90-90 targets — ambitious global goals for the scale-up of testing, treatment and adherence.
ITPC trained and supported national networks of people living with HIV to collect facility-level data along the HIV treatment cascade from 103 health centres in 11 West African countries. The majority of facilities in the sample were large public hospitals and mid-level health centres located in capital cities. From July 2017-June 2018, the regional community treatment observatory conducted 279 interviews and 110 focus group discussions with patients and services providers. Following several refinements to the quantitative data collection tool, 538 health facility visits were conducted from January-June 2018.
In this paper, we share the first year of monitoring findings from the regional community treatment observatory, analyzed using the ‘Five As’ framework — availability, accessibility, acceptability, affordability and appropriateness.
Availability: ART stockouts were recorded during 23.4% of health facility visits (95% confidence interval [CI] 19.8%-27.0%), lasting an average of 40.5 days (95% CI 34.2-46.7 days). Stockouts were less common for HIV tests kits and viral load laboratory supplies (e.g. reagents). Accessibility: Long distances to health centres was the foremost cited barrier to HIV testing and ART. Linkage to care at the monitored facilities was high overall (4,692 positive tests; 4,354 ART initiations), but was lower among key and vulnerable populations, and in countries where ‘treat all’ is not yet policy. Among 81,817 people on ART, 16,491 viral load tests were performed in the six months of the study. Acceptability: A third of patients rated the quality of services a 3 or less out of 5. A quarter of viral load test results were returned within two weeks, with faster turnaround time associated with improved viral suppression (p<0.05). Affordability: Payment for care was not cited as a major barrier to services. Appropriateness: 16% of individuals who tested HIV-positive were members of key and vulnerable populations, yet these groups made up just 7% of people on ART. Young men were less likely to access services than young women.
These findings highlight key gaps along the treatment cascade. Ongoing monitoring by communities of people living with HIV is critical to hold governments accountable for the 90-90-90 targets.