In late 2015, the World Health Organization announced new treatment guidelines recommending that anyone who has tested positive for HIV should begin antiretroviral therapy (ART) as soon as possible. The Government of Namibia has adopted the “treat all” guidelines as national policy.
As health facilities in Namibia begin operationalizing the treat all policy, there are many unanswered questions about its broader effects. Project SOAR’s research is enhancing understanding of how the implementation of the treat all guidelines affects critical aspects of ART service quality as reflected by patient-level outcomes including 12-month retention, appointment attendance, and viral suppression as well as by health system outcomes (i.e., human and financial resources for health).
“Namibia is one of the earliest countries in Africa to implement treat all in response to the 90-90-90 goals,” explained Dr. Lung Vu of Project SOAR/Population Council and one of the study’s principal investigators. “Our study is providing evidence on how it is working in the field—both in larger, centralized facilities and in smaller community health centers.”
This is important given the country’s ongoing process to decentralize the health system and to shift ART initiation and management tasks from physicians to nurses in order expand access to ART in rural areas and reduce patient loads.
The study is examining treatment services one year before the introduction of treat all and one year after. The research team is collecting patient data on HIV testing, treatment initiation, retention and viral load from routine clinic records and service quality data from client interviews and focus groups with providers. The team is also looking at costs, estimating the annual ART-related cost per client, the distribution of the cost drivers, and how the unit cost per client differs for hospitals versus health centers.
Findings from the first phase show that Namibia has a strong foundation for implementing the treat all guidelines. For example, 90 percent or more of patients in both types of facilities—hospitals and health centers—were retained in care during the previous 12 months. Among those who had received a viral load test, similarly high proportions of patients achieved viral suppression.
“We also found that ART clients from both centralized and decentralized facilities are satisfied with the quality of care they are receiving,” continued Dr. Vu.
These results show that providing services through decentralized, community-based health facilities can expand access to HIV care and treatment in rural areas without compromising patient outcomes.
Yet, there were two issues that the research teams want to examine further in the second round of data collection. The first is the recording of viral load testing. Only 60 percent of ART patients had records of having received a viral load test in the past 12 months. And patients at decentralized sites fared worse than at central facilities.
Viral load testing is critical for knowing how well a facility—as well as a country—is doing in achieving the last 90 of the targets, namely viral suppression.
“One of our key questions to answer is where is the gap—why are the guidelines on viral load testing not being followed,” noted Dr. Vu.
The second issue is the difference in ART uptake by men and women. While there were no significant differences in key treatment outcomes between male and female patients, many more women were accessing care and treatment services than men, particularly in decentralized facilities where 70 percent of the sample were women.
“We want to dive a little deeper and see if this difference persists after treat all is introduced,” said Dr. Vu. “If so, we would recommend further examination of why many men living with HIV are not accessing care and how services can better attract men.”
Data on patient-level and health system outcomes one year after the introduction of treat all are being analyzed and findings will be available by the end of 2018.
Learn about Namibia’s foundation for implementing the “treat all” guidelines. Read More
Find out about patients’ and providers’ perspectives about treatment services during the early phase of implementation. Read More