Exploring the evolution of policies for universalantiretroviral therapy and their implementationacross three sub-Saharan African countries:Findings from the SHAPE study

Moses Kumwenda , Morten Skovdal , Alison Wringe , Thoko Kalua , HadijaKweka , John Songo , Farida Hassan , Rujeko Samanthia Chimukuche , MosaMoshabela , Janet Seeley & Jenny Renju
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Universal antiretroviral therapy (ART) strategies have dramaticallychanged HIV programming across sub-Saharan Africa. We exploredfactors that influenced the development, adoption and implementationof universal ART policies in Tanzania, South Africa and Malawi. Weconducted 26 key informant interviews and applied Kingdonsstreamsmodel to explore how problems, policies and politics converged toprovide a window of opportunity for universal ART roll-out. Weak healthsystems and sub-optimal care retention were raised asproblemsduringOption B+ implementation, which preceded universal ART , andpersisted after its implementation. The adoption and implementation ofOption B+policyfacilitated the uptake of universal ART.Politicsplayedout through pressures from different stakeholders to accelerate or slowdown implementation, from governments, civil society groups,researchers and donors. Policy processes leading to universal ART wereopen to pressures and influence. The extraordinaryfinancial supportwhich enabled the widespread and rapid implementation of universalART skewed the power balance and sometimes left little space forlocally-derived solutions to respond to specific health system abilitiesand epidemiological contexts. Donors may be more effective if theyensure a greater focus on strengthening the whole health system aswell as accounting for local contextual factors and recent policydevelopment histories when funding policy implementation.