Health systems' responses to the roll-out of antiretroviral therapy (ART) in India: a comparison of two HIV high-prevalence settings

Abstract

The government of India launched the free anti-retroviral therapy (ART) initiative in 2004 and the programme has since scaled up expansion in a phased manner. Programme authorities acknowledge problems in scale-up, yet discussions have been restricted to operational constraints, with little consideration for how local health system responses to HIV/AIDS influence the delivery of ART. This paper draws on the perspectives of key informants and people living with HIV (PLHIV) to compare delivery of ART in two ART centres in the States of Maharashtra and Andhra Pradesh at two distinct points of time. In 2005, data were collected through key informant interviews (KIIs) using interview guides and a survey of PLHIV using a semi-structured interview schedule. Differences were observed in the functioning and resources of the two centres, indicating different levels of preparedness which in turn influenced PLHIV's pathways in accessing ART. We examine these differences in the light of programme leadership, ownership and the roles of public, private and non-governmental organisation actors in HIV care. KIIs conducted during a follow-up visit in 2009 focused on changes in ART delivery. Many operational problems had been resolved; however, new challenges were emerging as a result of the increased patient load. An understanding of how ART programmes evolve within local health systems has bearing on future developments of the ART programme and must include a consideration of the wider socio-political environment within which HIV programmes are embedded.

Keywords:

• public sector programmes
• anti-retroviral therapy
• health systems
• India

Acknowledgements

We express our gratitude to all participants in this study for sharing their experiences and insights with us. A special thanks to Swati Shinde and Saju Joseph for their assistance in coordinating data collection and data analysis during the first round of the study. This paper was originally presented at the University of East Anglia workshop on “Expanding anti-retroviral therapy (ART) provision in resource-limited settings” (May 2009) organised by the HIV and Development Group – we appreciate the comments received during the meeting and meticulous comments given by the eminent reviewers on the first draft. The study was conducted with financial support from RCSHA, DFID TB Knowledge Programme (Contract – HPD KP9) and DFID Communicable Diseases Research Programme Consortium – TARGETS (Contract – HD205).

Notes

1. Maharashtra, Tamil Nadu, Karnataka, Manipur, Andhra Pradesh and Nagaland are the HIV high-prevalence States in which ART was started in eight hospitals.

2. At the start of the programme the operational guidelines for the ART centres were in the draft stage. These guidelines evolved over time and were changed so as to overcome some of the operational problems faced during implementation. They were first made available on the NACO website in March 2007.

3. The guidelines provided detailed eligibility criteria for setting up ART centre, including information on infrastructural requirements, equipment and staffing in addition to the processes for requisition and acceptance of ARV drugs.