Identifying gaps in HIV service delivery across the diagnosis-to-treatment cascade: findings from health facility surveys in six sub-Saharan countries

Abstract

Abstract
Introduction: Despite the rollout of antiretroviral therapy (ART), challenges remain in ensuring timely access to care and
treatment for people living with HIV. As part of a multi-country study to investigate HIV mortality, we conducted health
facility surveys within 10 health and demographic surveillance system sites across six countries in Eastern and Southern
Africa to investigate clinic-level factors influencing (i) use of HIV testing services, (ii) use of HIV care and treatment and (iii)
patient retention on ART.
Methods: Health facilities (n = 156) were sampled within 10 surveillance sites: Nairobi and Kisumu (Kenya), Karonga
(Malawi), Agincourt and uMkhanyakude (South Africa), Ifakara and Kisesa (Tanzania), Kyamulibwa and Rakai (Uganda)
and Manicaland (Zimbabwe). Structured questionnaires were administered to in-charge staff members of HIV testing,
prevention of mother-to-child transmission (PMTCT) and ART units within the facilities. Forty-one indicators influencing uptake and patient retention along the continuum of HIV care were compared across sites using descriptive
statistics.
Results: The number of facilities surveyed ranged from six in Malawi to 36 in Zimbabwe. Eighty percent were governmentrun; 73% were lower-level facilities and 17% were district/referral hospitals. Client load varied widely, from less than one up
to 65 HIV testing clients per provider per week. Most facilities (>80%) delivered services or interventions that would support
patient retention in care such as delivering free services, offering PMTCT within antenatal care, pre-ART monitoring and
adherence counselling. Many facilities under-delivered in several areas, however, such as targeted testing for high-risk groups
(21%) and mobile testing (36%). There were also intra-site and inter-site differences, including in the delivery of Option B+
(ranging from 6% in Kisumu to 93% in Kyamulibwa), and nurse-led ART initiation (ranging from 50% in Kisesa to 100% in
Karonga and Agincourt). Only facilities in Malawi did not require additional lab tests for ART initiation. Stock-outs of HIV test
kits and antiretroviral drugs were particularly common in Tanzania.
Conclusions: We identified a high standard of health facility performance in delivering strategies that may support
progression through the continuum of HIV care. HIV testing policy and practice was particularly weak. Inter- and intracountry differences in quality and coverage represent opportunities to improve the delivery of comprehensive services to
people living with HIV

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ORCID for Victoria Hosegood: orcid.org/0000-0002-2244-2518

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