The World Health Organization has recently recommended ART for all people living with HIV through a policy initiative known as ‘treat all’. This also includes recommendations for service delivery, differentiated care and clinical monitoring. Many countries have struggled to provide ART and other related services at lower CD4 eligibility thresholds, largely due to financial constraints, limited infrastructure and insufficient resources. These difficulties are likely to be compounded by the growing number of patients in need of chronic HIV care.
This thesis focuses on Zimbabwe as a case study to investigate how WHO guidelines, including the most recent ‘treat all’ policies, are adopted and operationalized within the local health system and evaluate whether the anticipated patient level-benefits are achieved. This is done by applying descriptive, multilevel regression, and survival analysis methods to newly collected data. I begin by exploring the national policy environment, comparatively and descriptively assessing published guidelines from 2010 to 2016 in relation to WHO recommendations. Chapters go on to explore the implementation of these policies within health facilities, and their effect on clinical care and treatment outcomes.
Overall, findings indicate that while the uptake of WHO recommendations is progressive and far-reaching in Zimbabwe, the availability of resources, and the provision of certain policy mandated services recedes with decentralised care. Higher rates of attrition were observed following the introduction of treat all (p<0.0001), with predictors of this found to be younger age and the absence of CD4 monitoring at baseline. Taken together, these results suggest that despite the acknowledged deficiencies of health systems in sub-Saharan Africa, there is cause for optimism in the large-scale provision of ART. Additional efforts however are needed to ensure the sustained provision of ancillary services, such as laboratory monitoring to evaluate viral suppression, and the provision of isoniazid preventative therapy.