Progress and challenges in implementing HIV care and treatment policies in Latin America following the treatment 2.0 initiative

The typical Treatment 2.0 JRMs format includes three-phases: 1) a preparatory phase during which the team in the country collects and analyzes data on the HIV situation in general and on ART in particular. To ensure broad inclusiveness, an opportunity is provided for in-depth dialogue between national authorities and representatives of civil society and scientific communities; 2) the visits of an international team interacting with all the key actors identified, to finalize the analysis of the situation with special focus on the initiative’s five main priority areas. Based on this situation analysis, visits are prioritized to governmental and nongovernmental facilities providing HIV care and treatment such as hospitals, public health laboratories, pharmacies, national institutes of health, and interviews are held with key informants. At the end of the visit, the joint team develops recommendations and a short and medium-term national work plan for their implementation. The set of the country visit conclusions are presented to the highest representatives of the Ministry of Health and the National AIDS Program to ensure top-level support for implementing the plan; 3) implementation and monitoring of the recommendations.

This study aims to examine the degree of implementation of the Treatment 2.0 initiative in Latin American countries by analyzing to what extent the recommendations resulting from the JRMs have progressed, and assess the impact of these recommendations on health policies.

In order to assess the degree of implementation of the recommendations, an overall descriptive analysis was conducted among the first eight countries where PAHO and partners undertook this type of review mission: Ecuador, Venezuela, Bolivia, El Salvador, the Dominican Republic, Honduras, Argentina, and Guatemala. An in-depth cross-sectional analysis was also done in four selected countries based on the following criteria: 1) a mission conducted between 12 and 24 months prior to this monitoring exercise; 2) willingness of the national health authorities to participate in this exercise, and; 3) availability of different actors selected for the monitoring exercise. A standardized questionnaire was designed and used among one of each of the following key informants from each country: representative of the national ART programs, representative of civil society linked to ART programs in each country and a technical staff from the PAHO/WHO representation office of each country. The selected countries where this assessment was undertaken were Ecuador, Venezuela, Bolivia, and El Salvador.

The standardized tool was designed to collect the information related to the five priority areas of the Treatment 2.0 initiative [see Additional files 1 and 2]. The ‘strategic information’ area was added due to its cross-cutting importance in monitoring the implementation of the recommendations in each country. A color-coded ‘traffic light’ measure was introduced to indicate the progress made in each area, with red representing ‘implementation not yet underway’ , yellow ‘in progress’ and green ‘completed’. In addition, the measurement of the perception of progress of each recommendation was scored on a numerical scale based on the Likert scale, adapted to include different variables ranging from 0–5, where 0 = no progress (0 %), 1 = very early stage (20 %), 2 = initiated (40 %), 3 = in progress (60 %), 4 = at final stage (80 %), and 5 = completed (100 %) [14]. A column was also provided for comments on the implementation of each recommendation. The instrument was piloted by two local technical officers of PAHO in countries were the instrument was not applied to evaluate comprehension and consistency. Results were used to finalize the design of the tool. This standardized instrument was sent to all the selected key informants for self-completion.

A rating scale was established to measure the perception of the interviewees regarding the progress in implementing the recommendations of each priority area. For this, a differential percentage weight for each recommendation was applied to all priority areas, based on established multi-criteria analytical decision-making methodologies [15‐17]. Two major factors were also taken into consideration which affected the final attributed weight, the size of the population to be covered by the activity (national, regional or local), and the level of sustainability that the recommendation would achieve in the country. After this first classification was completed, the following secondary factors were applied in order of priority according to attributed percentage weight: a) an activity that needed to be undertaken prior to the other activities, and critical to allow continuity; b) an activity of strategic importance for formulating a national response and in line with international parameters; c) an intermediate activity that could have national impact or seriously interfere in the national process in the specific priority area; d) an intermediate activity with no significant impact on the national response or one that would not negatively impact the other activities in the same priority area; e) a minor activity that could impact on the national response and/or on the implementation of other activities; f) a minor activity with negligible impact on the other activities of the thematic area. The percentage of compliance was calculated based on the average score of recommendations for each priority areas by each key informant from each organization multiplied by the assigned percentage weight for each recommendation. Review of responses and all calculations were done by two of the authors separately (FP, BG) to assure compliance and validity. If different appreciations were found, response results were reviewed and compared and a final result was agreed upon. Incoherent answers were not considered after mutual agreement by the two authors. Results of the percentage of compliance are shown based on the number and type of recommendations by priority areas and country. When a priority area and/or a key informant are not shown, this is because the specific priority area did not have recommendation or the key informant did not respond to the survey.

To complement the assessment, a quantitative analysis of the optimization of antiretroviral drugs was conducted in three of the four countries where the implementation of the recommendations was systemically monitored (Bolivia, El Salvador, and Venezuela). This analysis was based on official data reported annually by the countries in the WHO AIDS Medicines and Diagnostics Service questionnaires regarding the use of antiretroviral drugs for 2013 (referring to 2012) and 2014 (referring to 2013) [3, 13, 18]. It was not possible to include Ecuador in this analysis since the country did not report in 2014. The aim was to document changes in the use of antiretrovirals in the countries that had received the Treatment 2.0 JRM, by conducting a comparative data analysis of antiretroviral use in 2012 (before the mission) and 2013 (after the mission). The following indicators were considered in order to compare the average values of the three countries in the two selected years: the number of first-line ART regimens in use; the percentage of patients in first-line ART regimens recommended by WHO (preferred and alternate); the percentage of patients in the preferred first-line ART regimens recommended by WHO (TDF + 3TC [or FTC] + EFV); the percentage of patients in first-line ART regimens including obsolete antiretrovirals (ddl, d4T, IDV, NFV); the number of second-line ART regimens in use; the percentage of patients in second-line ART regimens recommended by WHO; and the percentage of patients in second-line ART regimens including obsolete ARVs.

We reviewed the need for ethics approval with the Pan American Health Organization Ethics Committee who confirmed that given the nature of the study (retrospective survey through interviews) this work did not require ethics approval. All participants were informed about the study and provided oral informed consent to be included. Privacy and confidentiality were maintained throughout the study period; each questionnaire was number-coded without any personal identification.

Ecuador and Bolivia received the highest number of recommendations (29 each), followed by Honduras (n = 28) and Argentina (n = 20). The technical priority areas where the largest number of recommendations were focused were those corresponding to optimization of ART regimens (n = 57), followed by rational and efficient use of resources (n = 27) and provision of POC diagnostics and monitoring tools (n = 26) (Table 1). The review of the type of recommendations most frequently included in each technical priority area revealed the trends here below:

Overall, representatives from national ART program and international cooperation from each of the four countries completed the questionnaire. Civil society representatives from Ecuador and El Salvador who were identified and agreed to respond to the survey did not submit the completed questionnaire even after various reminders. The reason for this was not established. No incoherent answers were found.

In the four countries where structured interviews were conducted, most perceived progress was made in the rational and efficient use of resources priority area where average progress was perceived to be 62 %, followed by the optimization of ART regimens priority area (average 59.7 %). Meanwhile, progress in the priority areas of the adaption of delivery systems, community mobilization, and strategic information were rated at 52 %. Finally, the provision of POC diagnostics and monitoring tools scored the lowest (an average of only 38 %).

The optimization of ART regimens priority area received an overall average rating of 60 % progress in the four countries (Fig. 4). Detail review of this area showed scores for the recommendation on updating ART guidelines with an 80–100 % progresses in three of the four countries (El Salvador was rated at 60 %). The least progress perceived was related to the recommendation on plans of communication related to the optimization of ART regimens (0–60 %) and ART migration plans (30–60 %) (data not presented).

Limited progress was perceived in the priority area of provision of POC diagnostic and monitoring tools (less than 50 % in all the countries; average = 38 %) (Fig. 4). Although the updating of diagnostic algorithms, with the inclusion of HIV rapid tests, was the most common recommendation, it was perceived to have progressed by only 46 % on average. Meanwhile, the recommendations with the lowest levels of perceived progress were the decentralization of monitoring tests (viral load and CD4), averaging 20 %, and the inclusion of sample transportation strategies, with a perceived 22 % average of implementation (data not included in the graphic).

No recommendations were made on the ‘adaptation of delivery services’ priority area for El Salvador. Of the three remaining countries, Bolivia reported the highest average progress in this area (average 66 % based on responses from all key informants), although there was a substantial gap between interviewees (72 and 78 % for PAHO and NAP respectively, compared to 49 % for civil society). Venezuela had the lowest average perceived progress in this priority area (30 %), although civil society did not respond to the survey. Note that the Venezuelan NAP representatives perceived 60 % progress, while the international cooperation perceived no progress at all. (Fig. 5). The most frequent recommendation in this priority area was the decentralization of health care programs for which the perceived average implementation was scored at 50 % although this was reported in only two countries (Bolivia and Ecuador). The number of recommendations in this priority area was different in each of the four countries: seven recommendations were made for Bolivia, two for Ecuador, one for Venezuela and none for El Salvador.

Recommendations on community mobilization were made in only three countries. Progress achieved in this priority area was on average 50 %. However, it was not possible to obtain a realistic view of the implementation of this priority area in Venezuela and Ecuador since civil society (the main beneficiaries) did not participate in the survey, thereby limiting the value of the analysis. Despite this, Venezuela was perceived to have made progress in terms of community participation (76 %), followed by Ecuador (46 %) and Bolivia (40 %). The most frequent recommendation in this priority area was the need to implement communication and training strategies for civil society, designed to improve understanding and monitoring of the implementation of recommendations related to the other priority areas. The average progress of implementation was perceived at 54 % (data not presented). Implementation of the strategic information recommendations averaged 50 %. El Salvador and Bolivia had the highest perception of progress in this priority area (both with an average of 60 %) (Fig. 5). The most common recommendations in this area were the inclusion and updating of the HIV information system in the general health information systems. The implementation of both recommendations was perceived to have progressed by an average of 30 %.

A summary of the results of the analysis of the optimization of antiretroviral use in El Salvador, Venezuela and Bolivia is presented in Table 2. The quantitative analysis shows that there was a 36 % reduction in the average number of first-line ART regimens in use, from 11 in 2012 to seven in 2013. A similar trend can be observed for the second-line ART regimens. Over the same period, the proportion of patients on first-line regimens recommended by WHO increased from 74–78 % (5.4 % increase). The average use of the preferred WHO first-line ART regimen [TDF + 3TC (or FTC) + EFV] increased from 36–43 % (19.4 % increase) between 2012 and 2013 (it should be noted that for this indicator, results are discordant among countries and in Venezuela the use of the WHO preferred regimen declined from 63–43 % over the same time period). In addition, average use of the WHO preferred second-line ART regimens [AZT + 3TC (or TDF + XTC) + LPV/r (or ATV/r)] increased from 43–65 % (51 % increase) between 2012 and 2013. It is also noteworthy that there was a reduction in the use of obsolete ARV in first-line regimens. In 2013, only 1 % of people receiving first-line ART were still on regimens with didanosine (ddl) (no d4T-based regimen was reported). Finally, a reduction in the use of obsolete ARVs in second-line regimens was reported during the period under study. In 2013, 9 % of individuals on second-line ARV were still on regimens with ddl (no d4T-based regimen was reported).