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

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

The ever-growing HIV treatment programs in sub-Saharan Africa (SSA) present local policy makers with complex decision dilemmas, as international guidelines emphasize the need for expanded access to antiretroviral therapy (ART), yet funding has flatlined.

We argue that the current evidence base for prioritizing ART scale-up strategies results in recommendations that are theoretically optimal but practically infeasible to implement. Cost-effectiveness analyses (CEAs) of scaling up ART in SSA should be made more responsive to the needs of policy makers by taking into account the local health system.

We provide suggestions for a better integration of health system constraints into CEA by integrating supply- and demand-side constraints in mathematical models and improving the dialogue between researchers and policy makers.

February 27, 2017
Year of publication
Resource types
Journal and research articles
health system constraints, health systems, cost-effectiveness, policy makers, funding gaps, treatment, ART, antiretroviral therapy, ART scale-up

Similar Resources

Remarkable progress is being made on HIV treatment. Ahead of World AIDS Day, UNAIDS has launched a new report showing that access to treatment has risen significantly. In 2000, just 685 000 people living with HIV had access to antiretroviral therapy.

To understand the uptake of HIV services by adolescent women, the authors conducted a retrospective analysis of patient-level data (2011–2013) on services for antenatal care (ANC) and prevention of mother-to-child transmission (PMTCT) in 36 facilities in 5 districts in Zimbabwe.

In all countries where there is an HIV epidemic, certain subgroups of the population are at greater risk of HIV than others. These “key” populations include female sex workers (FSWs), men who have sex with men (MSM), transgender people, and people who inject drugs.

In late 2015, the Linkages Across the Continuum of HIV Services for Key Populations (LINKAGES) project established a global acceleration initiative to fast-track and strengthen delivery of a comprehensive package of health services for key populations (KPs) at scale. In this context, “…

Swaziland has one of the highest adult HIV prevalence rates worldwide, 27%; with approximately 200,000 people 15 years and older living with HIV. Swaziland and many other countries in sub-Saharan Africa have adopted universal test-and-treat (UTT) policies.

Malawi, like other countries with a generalized HIV epidemic, is striving to reach the ambitious targets set by UNAIDS known as the three 90's for testing, provision of antiretroviral therapy and viral suppression.

In 2006, WHO set forth its vision for a public health approach to delivering antiretroviral therapy. This approach has been broadly adopted in resource-poor settings and has provided the foundation for scaling up treatment to over 19·5 million people.

Antiretroviral therapy (ART) that enables suppression of HIV replication has been successfully rolled out at large scale to HIV-positive patients in low-income and middle-income countries.

In 2016, an estimated 1.5 million females aged 15-24 years were living with human immunodeficiency virus (HIV) infection in Eastern and Southern Africa, where the prevalence of HIV infection among adolescent girls and young women (3.4%) is more than double that for males in the same age range (1…

Over the past two decades, the landscape of medications used to treat HIV has evolved rapidly. Treatment options have improved dramatically with the development and availability of more efficacious, safer, and more tolerable antiretrovirals (ARVs).