The face of the HIV epidemic has dramatically changed on the African continent since the introduction of antiretroviral (ARV) drugs. Care and antiretroviral treatment (ART) programs have been scaled up in less than a decade and services for the prevention of mother-to-child transmission of HIV (PMTCT). The “3 by 5” initiative of the World Health Organization (WHO), followed by the launch of the Global Fund to Fight AIDS, Tuberculosis, and Malaria and the US President's Emergency Plan for AIDS Relief have created a new financial and organizational context within which treatment and prevention are no longer opposed.
Pilot programs were critical in the early days of this new era in bringing evidence that ART could be introduced in fragile health systems throughout the African continent,1 was acceptable by the populations in need,2 and resulted rapidly in positive outcomes, namely improved survival of adults3 and children4 and pediatric HIV infections averted.5 The French National Agency for Research on AIDS and Viral Hepatitis (ANRS) contributed to this pilot phase by accompanying some of the very first ART and PMTCT programs especially in Senegal and Côte d'Ivoire and thus produced some of the data needed by the international community to move to the scaling-up phase.
In less than a decade, incredible progress has thus been achieved as exemplified in the last WHO universal access report.6 Indeed, 52% of the adults in need of treatment worldwide were estimated to be treated with ART by the end of 2009, thatis, more than 5.2 million of people living with HIV/AIDS (PLWHA). The level of success was comparable for PMTCT with 53% of pregnant women living with HIV receiving ARVs for PMTCT worldwide. This achievement was in fact the combination of very diverse country situations. Overall, Africa has been doing as well than the other low-income and middle-income regions of the world: the 2009 ART coverage was 53% and the PMTCT coverage 54%. However, the African continent is usually divided in 4 subregions by WHO and for the purpose of the universal access report was described according to 2 distinct patterns.6 In Eastern and Southern Africa, ART coverage reached 59% and ARVs were used for PMTCT by 68% of the pregnant women in need. The situation was far less favorable in West and Central Africa with coverage of 36% only for ART and a desperately low figure of 21% for PMTCT. West and Central Africa is a complex patchwork of 25 countries with various historical background, political, economic contexts, and different HIV epidemics. However 3 following characteristics must be highlighted: (1) Nigeria, harbors the second largest population of PLWHA on the African continent; (2) 16 of these 25 countries share French as official language; and (3) West and Central Africa has received little US President's Emergency Plan for AIDS Relief bilateral support except for Nigeria and Côte d'Ivoire. West and Central Africa are thus in need for an in-depth characterization of the country strengths and weaknesses of their ART and PMTCT services and for the development of innovative solutions to strengthen these programs.
Implementation and operational research (IOR) is now recognized as a critical element to help better inform policy and guidelines for routine HIV care.7 It is, however, still a broad domain covering topics ranging from the evaluation of program outcomes to the assessment of new strategies to achieve better coverage and/or greater impact at population level with interventions of already validated efficacy. Thus, IOR aims to demonstrate that one can learn by doing in a public health way. In a recent report on their experience of IOR to improve ART scale-up in a joint partnership between the Ministry of Health of Cameroon and ANRS, Boyer et al8 have proposed 3 attributes for any IOR project: (1) Its finality is clearly operational as IOR results must translate into policy and practice; (2) Most if not all the IOR experiences are country-specific as they must integrate societal, psychosocial, and behavioral parameters in their design, conduct, and interpretation of results; and (3) All methods are acceptable to fulfill the IOR objectives and the randomized control trial design is not necessarily the first-choice approach when dealing with evaluation in the context of routine care.
ANRS has a well-known track record of encouraging and supporting HIV/AIDS (and more recently viral hepatitis) research in low-income countries. Overall, ANRS spends about a fourth of its annual operating budget on projects in low-income countries, and this proportion has increased over time. Although not exclusive, ANRS efforts are targeted towards so called ANRS sites, that is, priority countries where a research portfolio is organized after discussion with national authorities, constructed in close partnership between French and national researchers, and then conducted in coherence with the country needs. Not surprisingly, 6 of the 8 ANRS sites share French as a common language and 4 of them are in West and Central Africa: Burkina Faso, Cameroon, Côte d'Ivoire, and Senegal. Owing to the challenges faced by HIV programs in this part of the world, as documented by the 2010 universal access report indicators, ANRS attempted to stimulate in the past 4 years an IOR agenda on some of the major stumbling blocks already identified: uptake of HIV screening and PMTCT services, optimization of case management, and efficiency and equity in access to care.
The 10 manuscripts published in this JAIDS: Journal of Acquired Immunodeficiency Syndromes supplemental issue provide some insights on the IOR experience sponsored by ANRS in selected francophone countries of West and Central Africa. Ekouevi reports on a novel and comprehensive evaluation approach of PMTCT activities at health facility level in Côte d'Ivoire, confirming that PMTCT coverage is still very limited in this country. The challenges faced in the practice of HIV testing are highlighted by 3 reports. Tchendjou tries to understand why and how pregnant women and their partner get tested for HIV under routine circumstances in Cameroon, information used to design a new couple-based counseling strategy. Oga explores in Abidjan, Côte d'Ivoire, the attitudes and practices of a sample of health workers who had the potential to perform early pediatric HIV diagnosis; the report concludes that even when health professionals favor this new approach, the likelihood of success is impaired by lack of training. Suzan-Monti performs an in-depth investigation of the personal and structural factors that influence HIV status disclosure of PLWHA already in care to their main partner and concludes that psychosocial services linked to ART services are urgently needed in Cameroon although not originally budgeted in most programs. Four reports explore the problems encountered with the case management of HIV infection as a chronic disease. The survey performed by Muwonga et al in the difficult context of ART provision in the Democratic Republic of the Congo indicates that the acquisition of viral resistance can be a concern and requires proper surveillance efforts. Messou recommends to use the medication possession ratio as an in indicator of the risk of loss to follow-up based on Abidjan experience, whereas Roux concludes after conducting a nation-wide survey in rural Cameroon that medication reminder methods can improve ART adherence. Finally, Barro proposes and evaluates with success a simplified first-line regimen for children in Bobo Dioulasso, Burkina Faso. The last 2 reports are clear examples of barriers to access to treatment in West and Central Africa: d'Almeida quantifies the gap between the needs and the use of second-line ART in Cameroon; and Konate shares a successful experience of integration of care and treatment within a comprehensive preventive program targeting high-risk women in Bobo Dioulasso, Burkina Faso, where HIV incidence remains high.
The experiences reported here are limited in scope; some of them stop at the diagnostic stage or do not evaluate the proposed solutions. But they all fit with the proposed scope of IOR. The Sydney declaration stated in 2007 that 10% of all resources dedicated to HIV programs in low-income countries should be used for research optimizing interventions, with the hope to rapidly impact on program coverage and health outcomes.9 ANRS has initiated a few projects of this kind in francophone, Africa, with the aim to guide national policies and propose programatic solutions. We plea now for a much larger movement in favor of IOR, linking funding agencies, program managers and researchers to help in particular to reduce the gap between West and Central Africa, and other low-income regions of the world.
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