Exploring the evolution of policies for universal antiretroviral therapy and their implementation across three sub-Saharan African countries: Findings from the SHAPE study

Figures & data

Figure 1. Policy and implementation milestones for ART eligibility in regards to Universal ARTt.

Table 1. ARV treatment guidelines for prevention of mother-to-child transmission of HIV, Cited from Gourlay A et al. (Gourlay et al., 2013).

	Option A	Option B	Option B+
Mother (CD45350 cells/mm3)	Triple ARVs, starting from diagnosis and continued for life	Triple ARVs, starting from diagnosis and continued for life	Triple ARVs regardless of CD4 count, starting from diagnosis and continued for life
Mother (CD4350 cells/mm3)	Prophylaxis: Antepartum: AZT from 14 weeks gestation Intrapartum: sd NVP at onset of labour and AZT/3TC Postpartum: AZT/3TC for seven days	Prophylaxis: Triple ARVs from 14 weeks gestation until one week after exposure to breastmilk has ended
Infant	NVP (daily) from birth until one week after cessation of breastfeeding, or until age four to six weeks if replacement feeding	NVP or AZT (daily) from birth until age four to six weeks (regardless of infant feeding method)	NVP or AZT (daily) from birth until age four to six weeks (regardless of infant feeding method)

Note: ARV: antiretroviral; AZT: azidothymidine; NVP: nevirapine; sd: single-dose.

Figure 2. Schematic illustration of the policy process accounting for the context, the process and the actors.

Table 2. HIV demographics and ART policy and implementation milestones by country.

	United Republic of Tanzania	Malawi	South Africa
Total population in 2015^a	51.48 million	16.75 million	55.39 million
HIV demographics in 2015 (just prior to the universal ART recommendation)
Adults (15–49) prevalence^b	5.1%	9.9%	19.3%
AIDS related deaths among adults and children^b	32,000	15,000	89,000
Estimated women (15+) living with HIV^b	860,000	540,000	4,300,000
Estimated adults (15+) living with HIV^b	1,400,000	910,000	6,600,000
Adult (15–49) incidence (per 1000 uninfected population)^b	3.4	5.2	10.3
Pregnant women needing ART for PMTCT^b	81,000	48,000	32,000
Adults (15+) newly infected^b	79,000	37,000	81,000
ART Policy and Implementation Milestones
Year of public sector ART introduction	2003/4	2004	2003/4
Adult ART coverage in 2013a % (range)^c	41 (38–44)	51 (48–53)	42 (40–43)
Year of Option B+ introduction^c	2013	2011	2015
PMTCT coverage in 2013b % (range)^c	73 (65–83)	79 (71–88)	90 (83–95)
Donor funding as a proportion of total HIV/AIDS budget in 2013^d	50–74	75–100	0–24

^aThe World Bank IBRD.IDA.

^bUNAIDS HIV/AIDS estimated from 1990-present.

^cThe gap report. Geneva: Joint United Nations Programme on HIV/AIDS; 2014.

^dUNAIDS report on the global AIDS epidemic 2013. Geneva: Joint United Nations Programme on HIV/AIDS; 2013.

Table 3. Characteristics of the study participants.

Category		Country (Province)
		Malawi	Tanzania	South Africa (KwaZulu-Natal Province)
Sex	Male	8	5	0
	Female	2	6	5
Role	Technical advisor to the Government	2	0	0
	Country implementing partners	3	4	4
	Development partner	3	4	0
	Policy maker	1	3	1
	Academic	1	0	0
	Total	10	11	5

Figure 3. Illustration of the factors leading to the convergence of ‘streams’ which subsequently provided a window of opportunity for policy evolution.

Gourlay, A., Birdthistle, I., Mburu, G., Iorpenda, K., & Wringe, A. (2013). Barriers and facilitating factors to the uptake of antiretroviral drugs for prevention of mother-to-child transmission of HIV in sub-Saharan Africa: A systematic review. Journal of the International AIDS Society, https://doi.org/10.7448/IAS.16.1.18588

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Data availability statement

Data will be available for the next five years upon request to the study PI: [email protected].