Understanding how health systems providing ART in sub-Saharan Africa can generate even greater health benefits for their communities

Abstract

With the rapid scale up of testing and treatment for HIV, morbidity and mortality in sub-Saharan Africa have decreased dramatically. However, current treatment programmes providing ART are not maximally effective: they fail to identify infected individuals in a timely manner, resulting in millions of new infections and AIDS-related deaths per year. This thesis investigates why care programmes in sub-Saharan Africa do not succeed in achieving the full potential effects of ART – on both the risk of death and of onward transmission – and what can be done about it. I begin by exploring current treatment programmes using a framework known as the “Cascade of Care”, before detailing the development of an individual-based model that is able to track patients through care in western Kenya. I conclude that weaknesses exist throughout, attenuating the impact of individual interventions. However, a combination of interventions can improve patient outcomes more efficiently. I then find that through temporal and structural enhancements to the timing of home-based counselling and testing rounds, the UNAIDS 90-90-90 targets (90% of people with HIV diagnosed, 90% of those on treatment, and 90% of them virally suppressed) can be met by 2020. Finally, I explore the deficiencies in care across multiple countries utilising a simplified model encapsulating the concepts of the original but suitable for use with routinely available data. Overall, I conclude that current ART programmes in sub-Saharan Africa are not maximally effective due to deficiencies throughout care. However, I find that combinations of interventions targeting multiple aspects of care provide greater health outcomes (for a given cost) than “wide-scale test and treat” without accompanying fixes to the cascade, or interventions acting independently. International guidance for countries implementing ART programmes should recommend strengthening care across the cascade to generate greater patient outcomes and achieve international targets.