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Background: In the Asia-Pacific region, limited systematic assessment has been conducted on HIV service delivery models. Applying an analytical framework of the continuum of prevention and care, this study aimed to assess HIV service deliveries in six Asia and Pacific countries from the perspective of service availability, linking approaches and performance monitoring for maximizing HIV case detection and retention. Methods: Each country formed a review team that provided published and unpublished information from the national HIV program. Four types of continuum were examined: (i) service linkages between key population outreach and HIV diagnosis (vertical-community continuum); (ii) chronic care provision across HIV diagnosis and treatment (chronological continuum); (iii) linkages between HIV and other health services (horizontal continuum); and (iv) comprehensive care sites coordinating care provision (hub and heart of continuum). Results: Regarding the vertical-community continuum, all districts had voluntary counselling and testing (VCT) in all countries except for Myanmar and Vietnam. In these two countries, limited VCT availability was a constraint for referring key populations reached. All countries monitored HIV testing coverage among key populations. Concerning the chronological continuum, the proportion of districts/townships having antiretroviral treatment (ART) was less than 70% except in Thailand, posing a barrier for accessing pre-ART/ART care. Mechanisms for providing chronic care and monitoring retention were less developed for VCT/pre-ART process compared to ART process in all countries. On the horizontal continuum, the availability of HIV testing for tuberculosis patients and pregnant women was limited and there were sub-optimal linkages between tuberculosis, antenatal care and HIV services except for Cambodia and Thailand. These two countries indicated higher HIV testing coverage than other countries. Regarding hub and heart of continuum, all countries had comprehensive care sites with different degrees of community involvement. Conclusions: The analytical framework was useful to identify similarities and considerable variations in service availability and linking approaches across the countries. The study findings would help each country critically adapt and adopt global recommendations on HIV service decentralization, linkages and integration. Especially, the findings would inform cross-fertilization among the countries and national HIV program reviews to determine county-specific measures for maximizing HIV case detection and retention.
The study countries are Cambodia, Myanmar, Nepal, Papua New Guinea (PNG), Thailand and Vietnam. These countries were chosen based on the population size (5 to 100 millions), area (100,000 to 1,000,000 square kilometer), income level (low-income to upper-middle), type of HIV epidemics (concentrated), and willingness of the national HIV programs, World Health Organization (WHO) country offices, and FHI360 country offices to participate in the study. Among these countries, Thailand was categorized as an upper middle-income country and PNG and Vietnam were lower middle-income countries while the remaining three were categorized as low-income countries (see Table 1 for the characteristics of study countries, including population, HIV prevalence, and service coverage). By 2010, Cambodia and Thailand had reached high ART coverage; PNG and Vietnam just surpassed 50%; while Nepal and Myanmar remained far below 50% [19-24]. Myanmar and Thailand had achieved higher prevention of mother-to-child transmission (PMTCT) coverage than ART coverage. Brief characteristics of the study countries Remark: GNI: Gross national income. **AIDS Progress Report, 2012 of Cambodia [19], Myanmar [20], Nepal [21], PNG [22], Thailand [23], and Vietnam [24]. The COPC originates from the concept of the continuum of care developed in the 1970s to offer continuity of care for the elderly [25]. The continuum of care was then applied to individual case management of various health problems for strengthening service linkages and minimizing lost to follow-up. This concept was also applied for maternal, neonatal and child health [26]. In the 1990s, the continuum of care was introduced to HIV care [27,28]. Then in 2000s, the continuum of care was used to develop a common framework to coordinate multiple stakeholders in improving access to, and retention of ART for its scaling-up. In particular, the continuum of care facilitated linkages between health facility-based services and community- and home-based care (CHBC) and promoted the involvement of people living with HIV (PLHIV) [12-15]. The concept has further evolved to strengthen the linkages and integration between HIV prevention, care and treatment [29,30]. A critical element of the COPC is to establish a comprehensive care site as a central mechanism of a local service network. The comprehensive care site offers not only clinical care but a wide range of associated services. Such services include health education, psychosocial support, links to other services and CHBC, as well as opportunities for the involvement of affected communities such as key populations and PLHIV. The names given to the comprehensive care site differ across Asia, such as the Day Care Centre, the Comprehensive Continuum of Care Centre, and the Friend-Help-Friend Centre [13,15]. We applied an analytical framework of the COPC [18] to assess HIV service delivery in the six countries in the Asia-Pacific region (Figure 1). The assessment looked into four continuum: 1) service linkages between key populations outreach and health facilities through HIV testing and counseling services (Vertical-Community Continuum); 2) chronic care provision including self-care, peer support and patient follow-up and tracking as well as recording systems throughout the stages of HIV diagnosis and HIV care and treatment (Chronological Continuum); 3) linkages and/or integration across HIV and other health services (Horizontal Continuum); and 4) comprehensive care sites involving PLHIV and CHBC (Hub and Heart of Continuum). Analytical Framework of the Continuum of Prevention and Care (COPC). A regional team was formed to review national HIV health service delivery systems. The team consisted of officials from WHO Western Pacific Region, WHO South-East Asia Region, and FHI360 Asia Pacific Region as well as a consultant. The team adapted and adopted the COPC analytical framework that had been applied to a previous study in Vietnam [18]. Each country formed a review team which included national HIV program officials together with staff of WHO and/or FHI360 country offices. Assisted by an assigned focal point of the regional team, national HIV programs of respective country review teams identified and provided the information on the availability of HIV related services, approaches to link the services, and activities to monitor the performance. Data we collected were secondary program data from national HIV programs. Types of services covered included ART, HIV testing and counseling including voluntary counseling and testing (VCT) and provider-initiated testing and counseling (PITC) in TB and ANC services, CHBC, and HIV prevention for key populations. Global reports [31,32] were used to gather data on program performance including coverage of HIV testing, prevention and treatment as well as ART retention. For analyzing each continuum, data were examined to explore: contribution of service availability to the continuum; linking approaches taken to improve the continuum; and performance monitoring of the continuum. Regarding the vertical-community continuum, we looked into: distribution and decentralization of VCT and HIV prevention for key populations (service availability); approaches to accelerate access to HIV testing and counseling and referral to care among key populations (linking approach); and HIV testing and counseling coverage among key populations and other related indicators (performance monitoring). Concerning the chronological continuum, information examined include: distribution and decentralization of VCT and ART sites (service availability); approaches to improve retention from HIV testing to pre-ART enrolment, during pre-ART and during ART (linking approach); and status of monitoring systems on HIV testing to pre-ART, during pre-ART and during ART including national program data on ART retention and HIV drug resistance early warning indicators (performance monitoring). On the horizontal continuum, data analysis focused on continuum between HIV, ANC and TB services for HIV testing and counseling. For this, we examined: distribution and decentralization of ANC services, TB services and HIV testing and counselling including VCT and PITC for pregnant women and TB cases (service availability); approaches to link between HIV, ANC and TB services for HIV testing and counseling (linking approach); and HIV testing coverage among pregnant women and TB cases, ARV coverage for PMTCT, and TB treatment and ART coverage among HIV positive TB patients (performance monitoring). On the hub & heart of continuum, we analyzed the information on features and expansion status of comprehensive care sites including PLHIV involvement in ART sites and linkages with CHBC. Compiled data from each country was reviewed by the regional team, and additional information and clarifications were sought to complete the comparative analysis across the countries.
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