HIV policy implementation in two health and demographic surveillance sites in Uganda: findings from a national policy review, health facility surveys and key informant interviews
© The Author(s). 2017
Received: 12 April 2016
Accepted: 16 March 2017
Published: 5 April 2017
Successful HIV testing, care and treatment policy implementation is essential for realising the reductions in morbidity and mortality those policies are designed to target. While adoption of new HIV policies is rapid, less is known about the facility-level implementation of new policies and the factors influencing this.
We assessed implementation of national policies about HIV testing, treatment and retention at health facilities serving two health and demographic surveillance sites (HDSS) (10 in Kyamulibwa, 14 in Rakai). Ugandan Ministry of Health HIV policy documents were reviewed in 2013, and pre-determined indicators were extracted relating to the content and nature of guidance on HIV service provision. Facility-level policy implementation was assessed via a structured questionnaire administered to in-charge staff from each health facility. Implementation of policies was classified as wide (≥75% facilities), partial (26–74% facilities) or minimal (≤25% facilities). Semi-structured interviews were conducted with key informants (policy-makers, implementers, researchers) to identify factors influencing implementation; data were analysed using the Framework Method of thematic analysis.
Most policies were widely implemented in both HDSS (free testing, free antiretroviral treatment (ART), WHO first-line regimen as standard, Option B+). Both had notable implementation gaps for policies relating to retention on treatment (availability of nutritional supplements, support groups or isoniazid preventive therapy). Rakai implemented more policies relating to provision of antiretroviral treatment than Kyamulibwa and performed better on quality of care indicators, such as frequency of stock-outs. Factors facilitating implementation were donor investment and support, strong scientific evidence, low policy complexity, phased implementation and effective planning. Limited human resources, infrastructure and health management information systems were perceived as major barriers to effective implementation.
Most HIV policies were widely implemented in the two settings; however, gaps in implementation coverage prevail and the value of ensuring complete coverage of existing policies should be considered against the adoption of new policies in regard to resource needs and health benefits.
KeywordsHIV HIV policies Health services Uganda
The response to the HIV/AIDS epidemic has been unprecedented in its accumulation and application of research knowledge for policy and practice development . Significant progress has been made, as marked by the achievement of Millennium Development Goal 6, with an estimated 30 million new HIV infections averted and 7.8 million AIDS-related deaths prevented since 2000 . The effectiveness of treatment programmes in reducing HIV-related mortality, however, is predicated on effective implementation of policies around HIV testing, care and treatment to ensure timely treatment initiation and retention . Recent systematic reviews suggest heavy attrition of people living with HIV (PLHIV) at all stages of the care continuum, resulting in persistently higher mortality in the HIV-positive population compared to those who are HIV negative . This raises the question about the extent to which appropriate policies exist, the extent to which they are implemented and factors that facilitate or disable policy implementation.
Background characteristics of the study sites
Start of demographic data collection and serosurveys
Number of clinics (surveyed/total in HDSS)
Adults (15+ years) under surveillance, 2013
Introduction of ART
Full ART implementation
HIV prevalence (2013) (%)
HIV−ve mortality rate, 2009–2011 (per 1000)
Pre-ART HIV+ve mortality rate (2000–2003) (per 1000)
Post-ART HIV+ve mortality rate (2009–2011) (per 1000)
Reviewing policy implementation status, and assessing the influences that contribute, is critical for ensuring a more effective policy cycle, from formulation through to delivery, and back into re-formulation. This study aims to compare the status of implementation of policies promoting access to HIV testing, treatment and retention on treatment for facilities serving the population of two health and demographic surveillance sites (HDSS) in southern Uganda: Kyamulibwa and Rakai.
This analysis forms part of a larger study by ALPHA on HIV-related mortality; thus, the two Ugandan HDSS sites that contribute data to the ALPHA Network are investigated. Both HDSS are located in pre-dominantly rural Ugandan regions. Kyamulibwa, run by the UK Medical Research Council/Uganda Virus Research Institute, is located within Kalungu District and began collecting demographic and health data on the population in 1989 . Rakai, run by the Rakai Health Sciences Program, is located within Rakai District and began its open-community cohort for 15–49 year olds in 1994 . Background characteristics of the two sites are displayed in Table 1.
Policy review and document analysis
A review of Ugandan HIV policy documents was conducted in the study by Church et al. . This involved an online and library search for any relevant ministerial or national guideline documents on HIV counselling and testing (HCT), prevention of mother to child transmission (PMTCT) and HIV care and treatment published between 2003 and 2013. Staff from the Ministry of Health were also contacted in person in order to access all iterations of guidelines. The review captured detailed policy information (including year of formulation and any subsequent changes) for 54 indicators influencing access to HCT, access to care and treatment and retention in care. The content was reviewed and compared against successive iterations of WHO guidelines.
Health facility survey data and analysis
A health facility survey was subsequently carried out in 2013 by the ALPHA network to investigate reported practice in areas considered to influence access to HIV care services . Detailed methods are described elsewhere . In total, 24 facilities were surveyed. In Kyamulibwa, this included the three facilities located within the HDSS and a further six on the edge of or just outside the HDSS used by residents (n = 10). In Rakai, all facilities were surveyed except three very small clinics (n = 14). A structured questionnaire was administered to in-charge staff within three types of service units of participating facilities: HCT, PMTCT and ART services (the latter two where operational). Descriptive statistics were produced using STATA 13.0, including cross-tabulations of key indicators by site and by size of facility. Statistical tests were not conducted, as these were non-random samples, and not necessarily representative of a wider population of health facilities. Where data were missing, the denominator reflects the proportion of responses only, highlighted in the table.
Analysis to assess facility-level policy implementation
The policy review classified policies as explicit or not explicit (absent, vague or imprecise). Implementation of each policy was assessed using data from the health facility survey. Policies were defined as widely implemented if equal to or more than 75% facilities enacted the policy, partially implemented if implementation occurred in 26–74% of facilities and minimally implemented if 25% or fewer facilities reported implementation. Results were colour-coded green-orange-red to represent the degree of implementation, and dark or light shading was used to illustrate if policy was explicit or not explicit. Results were grouped into different policy domains, derived from the conceptual framework developed by Church et al.: service access and coverage, coordination of patient care and tracking, support to PLHIV, medical management and quality of care . Findings for quality of care are presented separately.
Key informant interviews
Seven semi-structured interviews were conducted with key informants who were purposively sampled based on their knowledge of the Ugandan HIV policy and practice context, including individuals with experience of policymaking (Ministry of Health, Uganda AIDS Commission), programme implementation (a donor partner relevant to the HDSS, a district health officer for a HDSS region and senior management from each HDSS) or HIV policy research in Uganda. Respondents were invited to participate by email, and informed consent was obtained. Interviews were conducted after the policy and practice comparisons had been undertaken to enable discussion of site-specific implementation gaps and to explore differences between sites. Interviews were conducted in-person or by telephone, recorded and transcribed. Follow-up interviews were conducted with respondents most familiar with programme implementation in the HDSS to investigate site-specific differences. Names and titles were removed to protect anonymity. Data were managed in Nvivo10. A deductive coding approach was used based on a priori knowledge of implementation theories, frameworks and models. The framework approach was used for analysis: data from each node (code) were extracted and entered into a matrix and memos were elaborated in order to reflect on the data and consider possible interpretations.
Overview of Kyamulibwa and Rakai HDSS included in facility survey
Total no. of clinics (n(%))
Type of facility (n(%))
Large clinic/small health center
Large health center/hospital
Management authority (n(%))
HIV-related services (n(%))
HIV counselling and testing
HIV care (incl. pre-ART) and treatment
HR and patient load (median (range))
No. of cliniciansa
No. of nurses/midwives
No. of counsellors
No. of HIV testing clients/week
No. of ART clients/week
No. of weekly HIV testing clients/staffb
No. of weekly ART clients/clinician or nurse
Findings of reported practice compared to policy
Across both sites, the majority of policies relating to HIV testing, treatment and retention in care were widely implemented; however, there was some variability between sites. The year of national policy adoption does not appear to influence implementation.
Implementation of policies promoting access to HIV testing
Implementation of policies promoting access to HIV treatment and PMTCT
Implementation of policies influencing retention on ART
Quality of care indicators
Facility implementation of quality of care indicators
Total no. of clinics (n(%))
National testing guidelines availablea
National treatment guidelines availablea
≤1 staff received HIV testing training in past 2 years
QOC audits at least once/year
At least one test kit stock-out in past year
Frequent test kit stock-outsb
CTX prophylaxis in stock in pre-ART
At least one stock-out 1st line ARVs in past year
Frequent stock-out of 1st line ARVsb
At least one stock-out of OI drugs in past yearc
Frequent stock of OI prophylaxisb
Influences on policy implementation: findings from key informants
Seven informants (four male, three female) with knowledge of the two HDSS were interviewed. Informants shed light on the patterns of reported implementation, possible reasons for differences between sites and the diverse political, social, structural factors influencing the translation of policy into practice in the Ugandan setting. Key informants were largely successful at predicting, when unprompted, which policies were well implemented and where implementation gaps existed in the two HDSS and along the treatment cascade. Reporting of reasons for differences was highly consistent between respondents, but senior members of the HDSS and the District Health Officer were most aware of implementation gaps. Findings have been detailed below under the domains detailed in Fig. 1 (characteristics of individuals and institutions, characteristics of intervention, processes and context).
Characteristics of individuals and institutions
For example, when [the WHO] said they upgrade to the CD4 500 we had a commitment from PEPFAR that they will be able to supply us with drugs for the additional number of people who are now eligible. Unless that is done we can’t support it. [R5]
The widespread implementation of many policies relating to treatment in Rakai was attributed to the volume of funding from PEPFAR, the Bill and Melinda Gates Foundation and support from the Department of Health, funds which were not received to the same extent in Kyamulibwa. Additionally, respondents noted that as facilities in the Rakai HDSS are pre-dominantly government-run and largely have the same funding source, there was coherence in communication among the facilities.
…the leadership of Ministry also really was very supportive of PMTCT as a whole… Then WHO supported us through the guidelines, and UNICEF [United Nations International Children’s Emergency Fund]. Everyone, all the organizations were very instrumental. [R3]
Those sorts of soft cuddly things really have been removed… For example, MRC [Medical Research Council] used to have a lot of community helpers groups, but in 2011 after that 5-year funding phase they just said no and that the money from DFID is just not there anymore, so it disappears. [R2]
Characteristics of the intervention
Option B+ has given us tangible results. Results that are visible by each and everyone[…], it’s one of those that have been implemented so well and we are increasingly getting HIV-negative babies born to HIV-positive mothers. [R6]
The support groups, it’s good in theory. [The AIDS Support Organization] has had some success… but it’s hard. A support group needs to be a group of local people who can help each other out… It’s not something that’s easy for a clinic to put in place. [R2]
Option B+, it was very successful because it was planned, it was a phased approach. We did not roll out to the whole country at once. We first went for the central region then we kept on rolling-out to other regions. [R5]
The process of monitoring progress, reflecting on results and adapting was also cited as critical, as well as demand-generation activities to engage PLHIV. It was acknowledged, however, that phased scale-up was necessary due to budget and resource constraints and one respondent described the prioritisation process as “political” and “very bureaucratic” [R5], thus causing unnecessary delays in implementation.
Innovations to simplify the treatment pathway for PLHIV were cited as an explanation for why some sites in Rakai did not widely implement policies that may act as a barrier to treatment initiation, e.g. only 50% of sites implemented the policy that recommends two adherence counselling sessions prior to ART initiation.
Respondents considered constraints on complete policy implementation to be attributable to a range of contextual factors, with one respondent commenting: “infrastructure and human resources are insufficient to implement the policies” [R1]. Some respondents, however, noted that Ugandan facilities fare well in terms of HIV service delivery compared with other countries in the region and that these HDSS facilities may also perform much better than others in Uganda: “if you went to the North of the Uganda, it’s absolutely luxury down in Rakai”. [R2]
Imagine, if you will, on a Monday morning where we have a clinic officer and he has about 100 to 120 clients that are coming in. This is extremely overwhelming and therefore impacting on the quality of services. [R7]
Sites don’t have dedicated logistics managers. The staff, she’s the doctor, she’s the nurse, she’s the soul, she’s everything. You need dedicated logistics managers. [R1]
Strategies for improving retention, of course one is infrastructure. If you improve infrastructure you improve clients flow, minimize waiting time, avoid stock-outs of essential drugs. I think all those we need to do … then tracking those clients who didn’t get lost to follow-up. [R1]
The political context was also influential, notably on policy and implementation gaps for testing and treatment services for MARPs, and it was noted that facilities may have been fearful to openly report provision of these services: “Because they won’t report they are doing that as it is illegal. There will be a lot of places that will be providing services for those people but not in name”. [R2]
This study has reviewed the implementation of HIV policy in Uganda within two rural HDSS in 2013. To our knowledge, this is the first comprehensive assessment conducted in the region that specifically contrasts the policy and practice of a range of indicators determinant in ensuring progression of PLHIV from diagnosis through to retention on long-term treatment.
The findings show that the majority of policies that may influence access to HCT, access to treatment for those diagnosed positive or retention in care were widely implemented across facilities in both sites. This is a notable achievement given the inherent health system weaknesses that can obstruct effective service delivery, which has been previously observed in many settings in Uganda .
There were, however, shortcomings either in both sites or in several areas. There were more commonalities than differences in implementation between the sites, with a similar pattern of practice observed for each policy (i.e. if Kyamulibwa reported wide implementation of a policy, so did Rakai), which suggests that factors influencing implementation may be common to both sites. However, Rakai achieved higher levels of implementation for policies relating to provision of treatment. Both Kyamulibwa and Rakai reported mixed implementation of policy indicators influencing retention in care (notably indicators providing support for PLHIV).
The qualitative findings identified a range of influences on policy implementation, usually facilitating practice rather than inhibiting. The commonalities between the implementation analysis and reports from informants give confidence to the accuracy of the self-report in the facility survey. Respondents highlighted several positive aspects of the policy cycle in Uganda, including substantial donor investment and support, phased implementation and routine hierarchical processes for information dissemination. However, informants strongly emphasised the inadequate quality of care and gaps in service provision considered to be common in the Ugandan context .
The pattern of implementation appears to follow the strength of recommendation and evidence-based for formulating it. Policies providing impactful results in the short term also appeared to be a strong enabling factor in implementation, as noted with the successful roll-out of Option B+. This may indicate evidence-driven policy implementation or reflect the donor-driven political environment in which it is preferable to deliver tangible results and maximum impact with the financial support they provide [5, 14]. As noted by our informants, such approaches may not always align with national priorities or local needs, with prevention activities often under-resourced. Emphasis by donors in support of medical management of HIV through ART may result in oversight of implementation of interventions supporting patient coordination or retention in care, which strengthen the comprehensive care package necessary for PLHIV to be maintained in the long-term care system. Retention strategies tend to have variable efficacy or may be complex to implement (as with patient support groups, noted by key informants) . This leads to a “vicious cycle” in which donors have little incentive to support such strategies, and less investment will result in less impact and less future evidence. The comparison is particularly stark when reviewed alongside implementation of clinical policies such as Option B+, as the successes will be harder to estimate or will appear over longer time horizons.
These oversights are particularly crucial given the recent changes to WHO guidance to recommend immediate ART initiation following HIV. The change in policy from Option A to Option B+ shares some similarities with this recent change in treatment eligibility by the WHO, and efforts should be made to learn from Uganda’s response to the former. This study indicates Option B+ was widely implemented across facilities within a short time frame due to support (political and economic) from individuals and institutions involved. Further, given that the policy was a simplification of a previous protocol, the training requirements were minimal, which enabled lower cadres of staff to perform the task. This bodes well for implementation of immediate ART as this is also a simplification of previous treatment protocol. However, the capacity of HIV programmes to retain high patient numbers in care may be of concern. In this study, facilities were already suffering stock-outs and human resource challenges; these systemic weaknesses are likely to be amplified with higher patient loads and development of resistance to ART may become increasingly problematic [16, 17]. While these changes in policy have the potential to markedly improve individual and population health, significant additional financial resources will need to be mobilised in the short term for commodities, laboratory facilities and facility-level and personnel costs [18, 19]. Pre-existing gaps in policy and practice along the diagnosis-to-treatment cascade could limit the effectiveness of this strategy .
Funding from international donors continues to be the main route through which HIV services are financed in Uganda; in 2011, it was estimated that 95% of the programme was funded by external donors, with PEPFAR responsible for 73% . Therefore, support for implementation of policies to improve the comprehensive care package provided to PLHIV will require donor backing. Key informants in this study reported on the complex dynamic of misalignment of goals between the government and donors in assessing priorities, making reference mostly to a lack of support for prevention activities, but also noting that support for health system strengthening would not be available . The Uganda AIDS Commission 2013 Country Progress Report indicate there is a need for support or leadership for strategies that enable strengthening of coordination of care and care provision for the later stages of the treatment continuum in which PLHIV should ultimately spend more time . The WHO’s 2015 ARV Guidelines include a number of operational recommendations on how to simplify and streamline care in order to reduce clinic burdens, and the adoption of such strategies should be considered if the programme is to sustain PLHIV in care over longer time horizons .
The facilities may not be representative of facility performance across Uganda, as routine research activities within the HDSS may have benefited service delivery. Health facility survey data may be affected by reporting bias, resulting in an overestimation of implementation, as managers may have been inclined to report practice in the best light. However, the number of gaps in implementation reported and the alignment with findings from key informants gives us confidence that reporting was relatively truthful. The policy and practice comparison presents a picture of a well-functioning health system; however, the qualitative interviews provide an alternative view. Human resources, infrastructure and health management information system limitations may be limiting the quality of care that is provided to patients, which might influence patient engagement with the health system . This generates hypotheses for further investigation to develop a deeper understanding of policy implementation. ALPHA’s ongoing qualitative research on the HIV continuum of care among people living with HIV in the HDSS may further inform findings on health facility performance and provider behaviour in this setting and help validate our findings. “Mystery client” patient observations, in particular, would prove insightful. This analysis was also not able to estimate the health impact of each policy, so it is difficult to draw conclusions about the effect that implementation gaps have on epidemiological outcomes.
This study provides insight into implementation status of MoH policies for HIV care in two HDSS sites in Uganda in 2013. While overall implementation was strong across the majority of policies, implementation coverage was frequently lower than 100% for many policies implying there is still a gap in complete implementation of most national HIV policies in Uganda, even in the relatively well-resourced HDSS. Key informants indicated that quality of care provided may have been limited in this setting, however, and noted the emphasis from donors to fund treatment, with minimal support for policies relating to coordination and retention of patients. Attention should be given to closing gaps in implementation (both at stages of the cascade and in the variability of facilities to adopt national policies) to improve the comprehensive care package that should be provided along the diagnosis-to-treatment cascade. This is particularly important as the country endeavours to respond to changing global guidance from the WHO, notably the change to immediate ART eligibility. While focus on entry into the care cascade remains vitally important, failure to ensure maintenance in care downstream in the care pathway could result in greater patient attrition from already overburdened facilities. Novel service delivery strategies to improve efficiency should be considered.
Network for Analysing Longitudinal Population-based data on HIV in Africa
Commercial sex workers
HIV counselling and testing
Health and demographic surveillance site
Human immunodeficiency virus
Health management information systems
Injection drug user
Isoniazid Preventive Therapy
Ministry of Health
Men who have sex with men
Presidents Emergency Fund for AIDS Relief
Prevention of mother to child transmission
Joint United Nations Department for HIV/AIDS
World Health Organization
We are grateful to all of our key informant participants and in-charge staff in the facilities for the time they dedicated to participate in this study. We also thank the reviewers of this manuscript for their valued comments and feedback.
The policy analysis and implementation research were funded through the ALPHA network by a grant from the Bill and Melinda Gates Foundation: “Deaths among HIV infected adults in African populations since the introduction of Antiretroviral Treatment” OPP1082114. AW is funded by a Population Health Scientist award, jointly funded by the UK Medical Research Council (MRC) and the UK Department for International Development (DFID) under the MRC/DFID Concordat agreement and is also part of the EDCTP2 programme supported by the European Union.
Availability for data and materials
The datasets created and/or analysed during the current study are not publicly available. Please contact the author with data queries.
AW, KC, BZ and JT are responsible for the initial conception of the ALPHA policy review and facility survey research in HDSS sites across the whole ALPHA network. EM and KC designed the protocol for the Uganda secondary analysis and key informant research. KC, JN FK, TL and BZ designed the policy review tool. KC, AW, JT, JN, TL and GN designed the health facility survey questionnaire. GN and FK conducted the policy review, with the inputs from TL and KC. JT, JN and GN oversaw the administration of the facility survey. EM designed the key informant topic guide with the inputs from KC. EM, KC and JE conducted the health facility survey data analysis; EM, KC and FK conducted the policy analysis. EM analysed the in-depth interview data. EM drafted and finalised the manuscript, with review and inputs from all co-authors. All authors read and approved the final manuscript.
The authors declare that they have no competing interests.
Consent for publication
Consent to publish facility survey results was obtained from in-charge staff in facilities. Consent to publish quotations from interview transcripts was obtained from all key informants.
Ethics approval and consent to participate
Ethical approval to collect health facility data and to conduct KI interviews was received from the Science and Ethics Committee of the Uganda Virus Research Institute, the IRB of record for both Medical Research Council and Rakai Health Sciences Program (reference number: GC/127/15/06/436) and registered with the Uganda National Council for Science and Technology. This research study was also approved by the ethics committee of The London School of Hygiene and Tropical Medicine (reference number: 9001). Uganda national policies for HIV were freely available online. All participants provided their written informed consent prior to the participation in the study.
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- Larson H, Bertozzi S, Piot P. Redesigning the AIDS response for long-term impact. Bull World Health Organ. 2011;89:846–52.View ArticlePubMedPubMed CentralGoogle Scholar
- UNAIDS. How AIDS changed everything. Geneva: UNAIDS; 2015.Google Scholar
- Mills EJ, Bakanda C, Birungi J, Chan K, Ford N, Cooper CL, Nachega JB, Dybul M, Hogg RS. Life expectancy of persons receiving combination antiretroviral therapy in low-income countries: a cohort analysis from Uganda. Ann Intern Med. 2011;155:209–17.View ArticlePubMedGoogle Scholar
- Kranzer K, Govindasamy D, Ford N, Johnston V, Lawn SD. Quantifying and addressing losses along the continuum of care for people living with HIV infection in sub-Saharan Africa: a systematic review. J Int AIDS Soc. 2012;15:17383.View ArticlePubMedPubMed CentralGoogle Scholar
- Uganda Ministry of Health. HIV and AIDS Uganda country progress report. Kampala: Uganda Ministry of Health; 2013.Google Scholar
- Reniers G, Slaymaker E, Nakiyingi-Miiro J, Nyamukapa C, Crampin AC, Herbst K, Urassa M, Otieno F, Gregson S, Sewe M, Michael D, Lutalo T, Hosegood V, Kasamba I, Price A, Nabukalu D, Mclean E, Zaba B. Mortality trends in the era of antiretroviral therapy: evidence from the Network for Analysing Longitudinal Population based HIV/AIDS data on Africa (ALPHA). AIDS. 2014;28:S533–42.View ArticlePubMedPubMed CentralGoogle Scholar
- Church K, Kiweewa F, Todd J, Oti S, Njage M, Mpandaguta E, Mugurungi O, Geubbels E, Mwangome M, Mamdani M, Dasgupta A, Nakiyingi-Miiro J, Gomez-Olive FX, Wringe A, Zaba B, Crampin A. A comparative analysis of national HIV policies in six African countries with generalised epidemics: influences on access to testing, access to treatment and retention in care. Bull World Health Organ. 2015;93:457–67.View ArticlePubMedPubMed CentralGoogle Scholar
- Putzel J. The politics of action on AIDS: a case study of Uganda. Public Adm Dev. 2004;24:19–30.View ArticleGoogle Scholar
- Dickinson C, Buse K. Understanding the politics of national HIV policies: the roles of institutions, interests and ideas. 2008.Google Scholar
- Walt G, Gilson L. Reforming the health sector in developing countries. Health Policy Plan. 1994;9:353–70.View ArticlePubMedGoogle Scholar
- Damschroder LJ, Aron DC, Keith RE, Kirsh SR, Alexander JA, Lowery JC. Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implement Sci. 2009;4:50.View ArticlePubMedPubMed CentralGoogle Scholar
- Slaymaker E, Bwanika JB, Kasamba I, Lutalo T, Maher D, Todd J. Trends in age at first sex in Uganda: evidence from Demographic and Health Survey data and longitudinal cohorts in Masaka and Rakai. Sex Transm Infect. 2009;85(Suppl 1):i12–9.View ArticlePubMedPubMed CentralGoogle Scholar
- Church K, Machiyama K, Todd J, Njamwea B, Mwangome M, Hosegood V, Michel J, Oti S, Nyamukapa C, Crampin AC, Nyaguara A, Nakigozi G, Michael D, Gomez-Olive FX, Nakiyingi-Miiro J, Zaba B, Wringe A. Identifying gaps in HIV service delivery across the diagnosis-to-treatment cascade: findings from health facility surveys in six sub-Saharan countries. J Int AIDS Soc. 2017;20:21188.View ArticleGoogle Scholar
- Orem JN, Mafigiri DK, Nabudere H, Criel B. Improving knowledge translation in Uganda: more needs to be done. Pan Afr Med J. 2014;17(Suppl 1):14.PubMedPubMed CentralGoogle Scholar
- World Health Organization. Retention in HIV programmes. Geneva: World Health Organization; 2012.Google Scholar
- Gupta RK, Jordan MR, Sultan BJ, Hill A, Davis DHJ, Gregson J, Sawyer AW, Hamers RL, Ndembi N, Pillay D, Bertagnolio S. Global trends in antiretroviral resistance in treatment-naive individuals with HIV after rollout of antiretroviral treatment in resource-limited settings: a global collaborative study and meta-regression analysis. Lancet. 2010;380:1250–8.View ArticleGoogle Scholar
- Barth RE, van der Loeff MFS, Schuurman R, Hoepelman AIM, Wensing AMJ. Virological follow-up of adult patients in antiretroviral treatment programmes in sub-Saharan Africa: a systematic review. Lancet Infect Dis. 2010;10:155–66.View ArticlePubMedGoogle Scholar
- Dutta A, Barker C, Kallarakal A. The HIV treatment gap: estimates of the financial resources needed versus available for scale-up of antiretroviral therapy in 97 countries from 2015 to 2020. PLoS Med. 2015;12.
- Stover J, Gopalappa C, Mahy M, Doherty MC, Easterbrook PJ, Weiler G, Ghys PD. The impact and cost of the 2013 WHO recommendations on eligibility for antiretroviral therapy. AIDS. 2014;28(Suppl 2):S225–30.View ArticlePubMedGoogle Scholar
- Bernstein M, Oomman N, Rosenzweig S. Following the funding for HIV/AIDS: a comparative analysis of the funding practices of PEPFAR, the Global Fund and World Bank MAP in Mozambique, Uganda and Zambia. Cent Glob Dev. 2007;2007:1–75.Google Scholar
- World Health Organization. Guideline on when to start antiretroviral therapy and pre-exposure prophylaxis for HIV. Geneva: World Health Organization; 2015.Google Scholar
- Slaymaker E, Todd J, Marston M, Calvert C, Michael D, Nakiyingi-Miiro J, Crampin A, Lutalo T, Herbst K, Zaba B. How have ART treatment programmes changed the patterns of excess mortality in people living with HIV? Estimates from four countries in East and Southern Africa. Glob Health Action. 2014;7:1–10.Google Scholar
- Uganda Ministry of Health. Uganda antiretroviral treatment guidelines. Kampala: Uganda Ministry of Health; 2011.Google Scholar
- Uganda Ministry of Health. The integrated national guidelines on antiretroviral therapy prevention of mother to child transmission of HIV infant & young child feeding. Kampala: Uganda Ministry of Health; 2012.Google Scholar
- Uganda Ministry of Health. Addendum to the national antiretroviral treatment guidelines. Kampala: Uganda Ministry of Health; 2013.Google Scholar
- Uganda Ministry of Health. Uganda national antiretroviral therapy adherence strategy. Kampala: Uganda Ministry of Health; 2011.Google Scholar