Evolution of prevention of mother to child transmission of HIV policy in Zambia: Application of the policy triangle to understand the roles of actors, process and power

Figures & data

Table 1. Documents reviewed.

Document/Report	Year/Period	Relevance to the study
1. Zambia national health strategic documents
Elimination of mother-to-child transmission of HIV and Syphilis. national operation plan 2019–2021	2019	Elimination of mother-to-child transmission of HIV and Syphilis. National operation plan 2019–2021
Zambia national health strategic plan	2017–2021	It gives the MOH strategic priorities and direction
National AIDS/HIV/STD/TB Council ‘Zambia National AIDS Spending Assessment 2015-2017’	2019	Document provided insights on the national HIV/AIDS spending
Ministry of Health Evaluation of the prevention of mother-to-child transmission of HIV programme in Zambia 2014–2916	2018	Provides insights into the impact of PMTCT programme in the country
Zambia population-based HIV impact assessment 2016	2016	Measure the status of Zambia’s national HIV response
Zambian consolidated guidelines for prevention and treatment of HIV infections	2014 & 2016	Acts as a reference on the best clinical practices in the prevention, treatment and management of HIV infections in Zambia
Ministry of health: national antiretroviral programme: Business case for an improved eMTCT Protocol in Zambia: Moving to Option B+	2012	This document details the country’s requirements for Option B+ Implementation
Zambia demographic health survey	2007 & 2018	Provide data for planning, implementation and monitoring and evaluation of national health programmes
2. WHO HIV/AIDS Guidelines
WHO updated recommendation on first-and-second line antiretroviral regimens.	2019	These documents provide global clinical recommendations on the use of ARVs but also address operational aspects along the cascade of HIV care-related services. This includes testing, ARVs for HIV prevention, linkage and enrolment into care, retention and adherence in general HIV care and treatment of comorbidities, when to start antiretroviral therapy and preferred ART regimens
Antiretroviral drugs for treating pregnant women and preventing HIV infections in infants: Towards universal access: Recommendation for a public health approach	2013, 2014 and 2016

Table 2. Key Informants interviewed for the study.

	Gender		Cadre Type		Experience/Involvement
	Female	Male	Nurse	Medical Doctor	16+ (years)	In PMTCT	Level of involvement in policy process
Key Informant #1	✓			✓	✓	Policy implementation	National
Key Informant #2		✓	✓		✓	Policy development, research	National implementing partner
Key Informant #3	✓			✓	✓	PMTCT specialist	National
Key Informant #4	✓		✓		✓	Policy development, research	National implementing
Key Informant #5		✓		✓	✓	Policy and research	Local national cooperating partner
Key Informant #6		✓		✓	✓	Child specialist	National
Key Informant #7	✓		✓		✓	Advocacy, research	National
Key Informant #8	✓		✓		✓	Policy development	International non-governmental organisation
Key informant #9		✓		✓	✓	Programme manager	National implementing partner
Key Informant #10	✓		✓		✓	PMTCT coordinator	International non-governmental organisation
Key Informant #11		✓		✓	✓	Policy implementation	National implementing
Key Informant #12	✓		✓		✓	Research	National
Key Informant #13	✓			✓	✓	Consultant, policy development	National
Key Informant #14		✓		✓	✓	Lecturer/Consultant	National/Academician

Note: Participants were mainly drawn from the national PMTCT technical working group, local and international NGOs.

Table 3. Selected codes, categories and themes for the data analysis.

Codes	Themes	Category	Source
Content	Situation analysis	Scope of PMTCT policies	Document review
	Voices from the street	Challenge in policy implementation
	Adoption and adaption
	Lack of monitoring and evaluation
Context	Use of sub-optimal ARVs	Presence of evidence	Document review
	Economic threat	Global plan
	Global support
	Global elimination plan 2011
Process	In country lobby by UNICEF	Policy process	Interview transcription
	WHO endorsement	Challenges in the process (health system readiness)
	Donor support
	National strategy
	TWG
	Male involvement
	Health system readiness	Humana resource	Interview transcription and document review
		Policy Implementation
		Supply chain
		TWG
Actors	Contribution of stakeholders	Role of stakeholders	Interview transcription
	Drivers of the agenda	Influence of policy

Figure 1. The key findings of the study according to the framework. Source: PEPFAR (President’s Emergency Plan for AIDS Relief); CDC (Centre for Disease Control and Prevention); WHO (World Health Organization); UNZA-SOM (University of Zambia School of Medicine); CHAI (Clinton health Access Intitiative); CHAZ (Chruches Health Associatrion of Zambia); and CSO (Civic Society Organizations).

Figure 2. Description of PMTCT Policy changes over time in Zambia. Source: SD = single-dose; NVP = nevirapine; AZT = azidothymidine; and NAT = nucleic acid test.

Table 4. Total spending on HIV in Zambia by source between 2015 and 2017.

	2015 (USD)	2015% Share	2016 (USD)	2016% Share	2017 (ZMW)	2017% Share
Public Source (incl.est MOH HR Spend)	53,298,769.00	14%	48,215,269.00	14%	65,883,033.00	14%
Global Funds	93,215,482.00	24%	60,970,084.00	17%	89,008,715.00	19%
Government of the United States	225,142,545.00	59%	227,681,936.00	65%	313,016,050.00	65%
All others (INGOs, Governments, FBOs, etc.)	9,657,185.00	2%	12,548,724.00	4%	10,640,584.00	2%
Total (ZMW)	381,313,981.00	100%	349,416,013.00	100%	478,548,382.00	100%

Note: National AIDS/HIV/STD/TB Council (2019) ‘Zambia National AIDS Spending Assessment: HIV & TB Spending, 2015–2017’.

National AIDS Council. (2019). Zambia national AIDS spending assessment: HIV and TB spending, 2015-2017 (Issue July). UNAIDS.

 Google Scholar

Data availability statement

The dataset supporting this analysis is not available as the key informant interviews contain information that would make the participants identifiable, compromising their confidentiality.