Makombe and colleagues (2007), visited all 95 ART facilities in the public sector and all 28 ART facilities in the private sector in Malawi, in 2006, constituting the first study from sub-Saharan Africa examining the important interaction between ART scale-up for health workers at a national level. Of the 1024 health workers studied, TB was a common stage-defining condition in 192 (18.8%) health workers, and was significantly more common in ward support staff (23.3%) compared with all other cadres. Of particular importance, was the finding that of health workers started on ART, more nurses (24.0%) and clinicians (16.4%) had accessed therapy at the time when this treatment had to be paid for compared with other cadres (7.5%), and had therefore a longer average exposure to ART. Health workers in stages 3 and 4 of the disease experienced a 70% reduction in mortality at 12 months. The 250 health workers who survived due to ART would account for a gain of 1000 health-care worker days per week at the national level. This balances favourably against the approximately 1000 health worker days per week that are required for ART service provision at the national level. These findings provide good evidence that providing free access to HIV treatment services for health workers is cost effective for the public health system as a whole.
Another study by Bezanson and colleagues presented at the International AIDS Conference in 2006 examined health worker initiation of ARV therapy and the outcomes of treatment for this population. This study revealed that health workers had an HIV associated mortality rate of 22.2% while the others in the study population had a mortality rate of 15.2%; 89% of health workers lived in close proximity to the ARV treatment centre that they accessed.
The authors conclude that timely initiation of ARV treatment for HIV positive health workers could help overcome the health human resource obstacle to increasing delivery of ARV treatment in resource poor settings. The study also revealed that health workers may be less likely than the general population to initiate ARV at an earlier stage of HIV infection and that their mortality rate may therefore be higher.
The WHO recently released a document entitled: "Integrating gender into HIV/AIDS programmes in the health sector: Tool to improve responsiveness to women's needs" (WHO 2009). The tool was field-tested in five countries: Belize, Honduras, Nicaragua, the Sudan and the United Republic of Tanzania. The tool was adapted and translated into Kiswahili and used to train HIV programme managers and service providers in two regions in Tanzania. It also provides guidance on how to sensitize senior programme managers and policy-makers to gender and HIV issues and remind programme managers and service providers of key gender-responsive HIV strategies. Issues surrounding gender-sensitivity, including those unique to male health workers, must also be considered when providing HIV and TB programmes and services. This document presents unique solutions to integrate gender into HIV programmes in the health sector and also advocates for gender-responsive health policies for female health workers.
Noteworthy from the 5-Country Study is the finding, as noted above, that while there was a strong willingness of health workers to obtain testing, this was often only if they were able to obtain priority access to ART in a non-stigmatizing and confidential setting. While the cost of the medication is not an issue, as also noted in the 17-country Surveys, time lost from work to obtain diagnosis and treatment was a serious barrier.
It is also noteworthy that the 17-country surveys conducted by the Steering Group found that health workers and families in all the countries were entitled to free HIV and TB services by policy, as was the case for the rest of the population. The study however also found that not all HIV essential package services were available in all the countries; for example some countries did not provide free condoms; some failed to provide free training of healthcare workers on HIV prevention, or free counselling and testing for families and some countries did not provide sufficient essential materials for prevention precautions; and free IPT was also not routinely provided.
Thus, there is strong evidence that providing free access to HIV and TB treatment services for health workers is cost effective for the public health system as a whole. While many countries already provide ART without charge, free convenient access to diagnostic and treatment services must still be addressed.
In reviewing the evidence, the GG highlighted the following aspects as particularly important for implementing this recommendation
- Free access includes ensuring drug availability, provision and delivery.
- Delivery should be carried out in a convenient and timeline manner.
- Free treatment should be provided at the point of service delivery.
- Despite substantial price reductions, it should be realized that there are still many ART related costs that remain in several regions.
- There should be no imposed user fees or institute co-payment mechanisms, particularly at the district or local level.
- Collaboration between HIV and TB services is essential.
- Adequate human resources should be established to allow for delivery of ARV drugs in all health facilities.
- Staff clinics must ensure provision of services in a non-stigmatizing, gender-sensitive and confidential setting.