Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2014 Apr 28;17(1):18908.
doi: 10.7448/IAS.17.1.18908. eCollection 2014.

A three-tier framework for monitoring antiretroviral therapy in high HIV burden settings

Affiliations

A three-tier framework for monitoring antiretroviral therapy in high HIV burden settings

Meg Osler et al. J Int AIDS Soc. .

Abstract

The provision of antiretroviral therapy (ART) in low and middle-income countries is a chronic disease intervention of unprecedented magnitude and is the dominant health systems challenge for high-burden countries, many of which rank among the poorest in the world. Substantial external investment, together with the requirement for service evolution to adapt to changing needs, including the constant shift to earlier ART initiation, makes outcome monitoring and reporting particularly important. However, there is growing concern at the inability of many high-burden countries to report on the outcomes of patients who have been in care for various durations, or even the number of patients in care at a particular point in time. In many instances, countries can only report on the number of patients ever started on ART. Despite paper register systems coming under increasing strain, the evolution from paper directly to complex electronic medical record solutions is not viable in many contexts. Implementing a bridging solution, such as a simple offline electronic version of the paper register, can be a pragmatic alternative. This paper describes and recommends a three-tiered monitoring approach in low- and middle-income countries based on the experience implementing such a system in the Western Cape province of South Africa. A three-tier approach allows Ministries of Health to strategically implement one of the tiers in each facility offering ART services. Each tier produces the same nationally required monthly enrolment and quarterly cohort reports so that outputs from the three tiers can be aggregated into a single database at any level of the health system. The choice of tier is based on context and resources at the time of implementation. As resources and infrastructure improve, more facilities will transition to the next highest and more technologically sophisticated tier. Implementing a three-tier monitoring system at country level for pre-antiretroviral wellness, ART, tuberculosis and mother and child health services can be an efficient approach to ensuring system-wide harmonization and accurate monitoring of services, including long term retention in care, during the scale-up of electronic monitoring solutions.

Keywords: HIV; TIER.Net; antiretroviral therapy; eKapa; electronic register; monitoring; three-tier system.

PubMed Disclaimer

Figures

Figure 1
Figure 1
Different candidate tiers of a multi-tier monitoring system.
Figure 2
Figure 2
A three-tier monitoring and evaluation system capable of working together in a health region (one choice per facility) to ensure all contexts have an appropriate and viable way to monitor care across all levels of the health services.
Figure 3
Figure 3
Evolution from paper systems to full EMR systems over time.

References

    1. World Health Organization, UNICEF, UNAIDS. Geneva: World Health Organization; 2013. Global update on HIV treatment 2013: results, impact and opportunities, June 2013.
    1. World Health Organization, UNAIDS. Geneva: World Health Organisation; 2004. Treating 3 million by 2005: making it happen: the WHO strategy: the WHO and UNAIDS global initiative to provide antiretroviral therapy to 3 million people with HIV/AIDS in developing countries by the end of 2005.
    1. Jaffe HW. Universal access to HIV/AIDS treatment: promise and problems. JAMA. 2008;300(5):573–5. - PubMed
    1. Rabkin M, El-Sadr WM, De Cock KM. The impact of HIV scale-up on health systems: a priority research agenda. J Acquir Immune Defic Syndr. 2009;52(Suppl 1):S6–11. - PubMed
    1. Granich R, Kahn JG, Bennett R, Holmes CB, Garg N, Serenata C, et al. Expanding ART for treatment and prevention of HIV in South Africa: estimated cost and cost-effectiveness 2011–2050. PLoS One. 2012;7(2):e30216. - PMC - PubMed

Substances