Renal health models in Latin America: development of national programs of renal health

PURPOSE: To verify the actions and degree of progress achieved in countries of Latin America and the Caribbean in the implementation of the Sustainable and Tenable Renal Health Model promoted by the Latin American Society of Nephrology and Hypertension (SLANH), together with local societies and the participation of the Pan-American Health Organization. (PAHO/WHO). METHOD: The implementation of workshops (e.g., "Toward a Sustainable and Tenable Renal Health Model") in each country involving health ministries, social security agencies, PAHO, scientific societies, medical organizations, and NGOs, among others, as well as start-up conferences with a special emphasis on local problems. Working teams will state the bases for planning, programming and evaluation in the Logical Framework Matrix and Matrix of Activities and Resources in the First Level of Care. The signature of the document "Declaration" with commitments undertaken by both public and private parties and a work schedule are required. RESULTS: So far, eleven countries in the region have conducted workshops and started activity in the frame of the Model/Program of Renal Health, which articulates the traditional vertical programs and generates a cross-program in the First Level of Care. Its components and strategies make up a cost-efficient control of cardiovascular, renal and endocrine-metabolic health. CONCLUSION: The Renal Health Model and its program is being built into public health care policies of countries in Latin America and the Caribbean and adapted to the needs of each country with an increasing acceptance on the part of health care professionals. It should not be implemented in isolation but within the framework of non transmissible diseases.     

Renal Health Models in Latin America: Development of National Programs of Renal Health

Purpose. To verify the actions and degree of progress achieved in countries of Latin America and the Caribbean in the implementation of the Sustainable and Tenable Renal Health Model promoted by the Latin American Society of Nephrology and Hypertension (SLANH), together with local societies and the participation of the Pan-American Health Organization. (PAHO/WHO). Method The implementation of workshops (e.g., “Toward a Sustainable and Tenable Renal Health Model”) in each country involving health ministries, social security agencies, PAHO, scientific societies, medical organizations, and NGOs, among others, as well as start-up conferences with a special emphasis on local problems. Working teams will state the bases for planning, programming and evaluation in the Logical Framework Matrix and Matrix of Activities and Resources in the First Level of Care. The signature of the document “Declaration” with commitments undertaken by both public and private parties and a work schedule are required. Results. So far, eleven countries in the region have conducted workshops and started activity in the frame of the Model/Program of Renal Health, which articulates the traditional vertical programs and generates a cross-program in the First Level of Care. Its components and strategies make up a cost-efficient control of cardiovascular, renal and endocrine-metabolic health. Conclusion. The Renal Health Model and its program is being built into public health care policies of countries in Latin America and the Caribbean and adapted to the needs of each country with an increasing acceptance on the part of health care professionals. It should not be implemented in isolation but within the framework of non transmissible diseases.     

Primary health care strategies for the prevention of end-stage renal disease in Cuba

End-stage renal disease (ESRD) is a major health problem in the world, including Cuba. There is an increasing trend in both the incidence and prevalence of ESRD. Global projections consistently show an increase of patients in maintenance dialysis, and also an epidemic trend in diabetes mellitus and hypertension, two diseases that are leading causes of ESRD in most countries. A new paradigm is necessary to handle this major health problem, such as a public health model that integrates health promotion and disease prevention. In 1996, the Ministry of Public Health of Cuba launched a national program for the prevention of chronic renal failure (CRF). The progressive implementation of this program follows several steps: the analysis of the resources and health situation in the country; epidemiological research to define the burden of CRF; continuing education for nephrologists, family doctors, and other health professionals; and reorientation of primary health care toward increased nephrology services, intervention, and surveillance. The main outcomes of the program have been: a rational redistribution of nephrology services in corresponding health areas of primary health care; nephrologists being brought closer to the community; an improvement in the knowledge and ability of family doctors and nephrologists in the prevention of chronic renal disease; an increase in the number of patients with CRF (serum creatinine > or = 133 micromol/L or > or = 1.5 mg/dL, or a glomerular filtration rate < 60 mL/min) who are registered in primary health care every year, from a prevalence of 0.59 per 1,000 inhabitants at the beginning of the program in 1996 to 0.92 per 1,000 inhabitants in 2002, with a mean prevalence growth of 9.2% per year; a significant reduction (0.1%) in the incidence of viral hepatitis B in dialysis patients after the implementation of vaccination against viral hepatitis B in CRF patients who are registered in primary health care; and the implementation of CRF surveillance in primary health care, which provides periodic information on CRF burden, patterns, and trends to assist evidence-based public-health decision making, and measures the impact of interventions in the population. Primary health care is an essential tool, and the community is an appropriate social space for health promotion and the prevention of CRF and ESRD.     

Epidemiology and Control of Hypertension and Diabetes in Costa Rica

Costa Rica is one of the countries that make up Central America, neighboring Nicaragua and Panama. Costa Rica shares with its neighbors the social and economic problems characteristic of developing countries; however, one difference is that Costa Rica can derive a great part of its budget and expense to health and education, as it had abolished the army in 1948. It is for this reason that Costa Rica shares diseases characteristic of their region like the Dengue, yet at the same time have a true explosion in the fields of hypertension (HTA), diabetes (DM), and cardiovascular disease.

The health system of Costa Rica has nearly universal coverage, reaching 98% of the population with primary and secondary diverse levels of attention that give appropriate and satisfactory treatment to all hypertensive and diabetic patients.

The HTA and the DM are true public health problems; however, before 2004, there weren't appropriate data on their prevalence and management. Small studies showed an increase in the prevalence of HTA from 9 to 24%, though no data on the prevalence of DM were available. In 2004, the Multinational Survey of Diabetes and Hypertension and Other Factors of Risk carried out in San José, Costa Rica, determined a prevalence of HTA of 25% and of DM of 8%. Likewise, the methodology of the survey allowed an evaluation of the quality of the attention of the HTA (Tracer of Arterial Hypertension) and, consequently, appropriate control of hypertensive patients in Costa Rica; through it, it was determined that greater effort was required for earlier detection and resource optimization to better handle hypertensive and diabetic patients and thus reduce cardiovascular morbidity-mortality and chronic renal disease.     

Epidemiology and control of hypertension and diabetes in Costa Rica

Costa Rica is one of the countries that make up Central America, neighboring Nicaragua and Panama. Costa Rica shares with its neighbors the social and economic problems characteristic of developing countries; however, one difference is that Costa Rica can derive a great part of its budget and expense to health and education, as it had abolished the army in 1948. It is for this reason that Costa Rica shares diseases characteristic of their region like the Dengue, yet at the same time have a true explosion in the fields of hypertension (HTA), diabetes (DM), and cardiovascular disease.The health system of Costa Rica has nearly universal coverage, reaching 98% of the population with primary and secondary diverse levels of attention that give appropriate and satisfactory treatment to all hypertensive and diabetic patients.The HTA and the DM are true public health problems; however, before 2004, there weren't appropriate data on their prevalence and management. Small studies showed an increase in the prevalence of HTA from 9 to 24%, though no data on the prevalence of DM were available. In 2004, the Multinational Survey of Diabetes and Hypertension and Other Factors of Risk carried out in San José, Costa Rica, determined a prevalence of HTA of 25% and of DM of 8%. Likewise, the methodology of the survey allowed an evaluation of the quality of the attention of the HTA (Tracer of Arterial Hypertension) and, consequently, appropriate control of hypertensive patients in Costa Rica; through it, it was determined that greater effort was required for earlier detection and resource optimization to better handle hypertensive and diabetic patients and thus reduce cardiovascular morbidity-mortality and chronic renal disease.     

Sustainable and tenable renal health model: a Latin American proposal of classification, programming, and evaluation

BACKGROUND: End-stage renal disease (ESRD) presents a major problem to public health, with complex implications for social and economic structures in every nation of the world. Clearly, Latin American and Caribbean countries are not able to meet the needs of every patient requiring dialysis treatment at ESRD. Consequently, a considerable number of patients die every year as a result of lack of resources. Aware of this serious social, ethical, and economic problem, the Latin American Society of Nephrology and Hypertension proposed a new renal health concept in the region. In December 2002, at the workshop in Valdivia, Chile, a modification to the National Kidney Foundation Classification of Chronic Kidney Disease was approved. PROJECT: According to modifications to the concept of chronic kidney disease approved in the Declaration of Valdivia, a new Renal Health Model was proposed. It consists of including orderly follow-up in patients' charts, starting from the earliest stage, and a model establishing a guideline for the reallocation of financial resources to guarantee continuity of treatment to patients with ESRD. CONCLUSION: The implementation of the Renal Health Program in health ministries of Latin American and Caribbean countries would allow for a substantial improvement in renal health prevention and management, as a result of better distribution of financial and human resources.     

Chronic kidney disease in Costa Rica

Costa Rica is one of the Central American countries, located between Nicaragua to the north and Panama to the south. Like other Latin American countries, Costa Rica deals with social and economic problems associated with poverty, except for one significant difference-Costa Rica has not had an army since 1948, and so the people and government can spend more money on education and health. For this reason, Costa Rica is very different from other Latin American countries. We do not need weapons, and we have had a democratic tradition for 100 years. Despite our economic and social limitations, Costa Ricans have universal access to a health system that covers 98% of the inhabitants. Renal replacement therapy (RRT) is accessible to all who need it. In the last 5 years, Costa Rica has doubled the number of patients on hemodialysis, and has the highest number of kidney transplants per million population (pmp) in Latin America, with 20.63 transplants pmp in 2000, 27.25 transplants pmp in 2001, and 24.81 transplants pmp in 2002. However, the prevalence of all forms of RRT in Costa Rica is currently 193 pmp. This suggests that end-stage renal disease is underdiagnosed in Costa Rica as it is in many other Latin American countries. Greater research efforts are needed to determine the true extent of renal disease in Costa Rica and to optimize the use of health-sector resources to provide a better and more robust program of RRT for patients with end-stage renal disease.     

The health system in Chile: the nephrologist perspective

Chile is a country with 17 million inhabitants, 13% of them living in rural areas, and with a per capita income of approximately US $14,500. Three percent of national income is assigned to the health budget, with a mixed public and private system, with guaranteed medical benefits from the state to cover chronic kidney disease (CKD) and renal replacement therapy (RRT). Hemodialysis has reached in 2009 a prevalence of 857 patients per million population (pmp). Peritoneal dialysis is less developed, with a prevalence of 40 patients pmp. Both therapies show good quality indexes with a patient mortality rate close to 12% per year. A centralized national renal transplantation program registered 5,949 renal transplants performed up to 2009. Renal survival at 5 years is 86% for living and 76% for cadaveric donor transplants. Organ donation is relatively low with 7.1 cadaveric donors pmp in 2009, despite legal and educational strategies to increase it. Although the country demonstrates one of the highest standards for RRT indexes in Latin America, the proportion of resources invested makes it necessary to improve early diagnosis and renal prevention policies to avoid having the growing incidence of CKD constrain the national health budget.     

Preventive strategies of renal failure in the Arab world

The prevalence of both acute and chronic renal failure is high in the Arab world. Data available on the exact prevalence of various renal diseases are very limited. Nevertheless, the reported prevalence of chronic renal failure is 80 to 120 per million population (pmp) in the Kingdom of Saudi Arabia and 225 pmp in Egypt. This is in comparison with the reported prevalence of 283 pmp in Europe, 975 pmp in the United States, and 1149 pmp in Japan. Lower prevalence rates reported in this region could be due to underreporting. The economic burden of renal replacement on health care providers is enormous. In the Kingdom of Saudi Arabia, the estimated cost per annum incurred toward maintenance hemodialysis is US 19,400 US dollars and, considering that there are more than 7200 patients on regular dialysis in this country, the total expenditure is enormous. Such large amounts may be beyond the monetary capacity of many countries in this region because of limited financial resources. These figures clearly suggest that there is an urgent need to establish a massive prevention program. The strategy adapted should be innovative and imaginative and should be one that is maximally cost effective. Paradoxically, in the Arab world, we have a good opportunity to reduce the incidence of kidney failure (chronic and acute) substantially by appropriately chosen models. This is because many of the causes of renal failure are eminently preventable. In fact, a rough estimate is that these programs, if successful, can reduce the incidence by as much as 40% (personal communication, Shaheen, 2003). It is worthy of mention that, in the Arab world, the budget for research is about 0.15% of the national domestic product compared with the international average of 1.5%. In this article, we concentrate on some of the main causes of renal failure in the Arab world that we feel can be prevented and suggest ways that can best address this issue.     

Access to and coverage of renal replacement therapy in minorities and ethnic groups in Venezuela

Access to and coverage of renal replacement therapy in minorities and ethnic groups in Venezuela. Numerous studies have documented the presence of racial and minority disparities regarding the impact of renal disease and access to renal replacement therapy (RRT). This problem is less well documented in Latin America. Venezuela, like most countries in the region, is subject to severe constraints in the allocation of resources for high-cost chronic diseases, which limits the access of patients with chronic kidney disease to RRT. Although access to health care is universal, there is both a deficit in coverage and disparity in the access to RRT, largely as a result of socioeconomic limitations and budget constrains. With current rising trends of the incidence of end-stage renal disease (ESRD) and costs of medical technology, the long-term goal of complete RRT coverage will become increasingly out of reach. Current evidence suggests that prevention of progression of renal disease is possible at relatively low cost and broad coverage. Based on this evidence, the Ministry of Health has redesigned its policy with respect to renal disease based on 4 elements: 1. Prevention by means of early detection and referral to multidisciplinary health teams, as well as promotion of health habits in the community. 2. Prevention of progression of renal disease by pharmacologic and nonpharmacologic means. 3. An increase in the rate of coverage and reduction of disparities in the access to dialysis. 4. An increase in the rates of renal transplantation through better organ procurement programs and reinforcement of transplant centers. However, the projected increase in the number of patients with ESKD receiving RRT will represent a serious burden to the health care system. Therefore, implementation of these policies will require the involvement of international agencies as well as an adequate partnership between nephrologists and health care planners, so that meeting the increasing demands of ESKD programs may be balanced with other priorities of our national health system.     

End-stage renal disease in the Asian-Pacific region

Information on end-stage renal disease (ESRD) is important in assisting health care providers in planning renal replacement therapy. A questionnaire was sent to various countries in the Asian Pacific region and 10 countries responded. Data from Australia and New Zealand was obtained from their registry report. The questionnaire requested information on incidence, prevalence, transplantation rate, demographic data, causes of ESRD, causes of death, and mortality rates for the years 1998 to 2000. All the countries surveyed had national registries and there was a greater than 90% response rate in 7 of 12 countries. The incidence and prevalence rates of ESRD were linked to funding of dialysis, with higher reported rates in countries where dialysis was totally or heavily subsidized by the government. There was an increase in both incidence and prevalence rates between 1998 and 2000, with the mean annual percentage increase of 1.2% to 14.1% for incidence and 4.2% to 17.3% for prevalence. Diabetic nephropathy was the most common cause of ESRD in 9 of the 12 countries surveyed and 6 of the 12 countries had greater than 35% of their dialysis patients age 60 years and older. Peritoneal dialysis (PD) use varied between 3.9% to 81% of the dialysis population and reflected the health care policies of the individual countries. The transplantation rate was influenced by socioeconomic, religious, and cultural attitudes and varied between 3.1 per million population (pmp) to 32 pmp with the percentage of cadaveric transplants ranging between 0% of 85% of total transplants. Cardiovascular mortality remained the most common cause of death in the ESRD patients. Collaboration between the various national registries in the form of specific international studies may yield useful information of ESRD patients in the Asian-Pacific region.     

A picture is worth a thousand words: maps of HIV indicators to inform research,programs, and policy from NA-ACCORD and CCASAnet clinical cohorts

Introduction

Maps are powerful tools for visualization of differences in health indicators by geographical region, but multi-country maps of HIV indicators do not exist, perhaps due to lack of consistent data across countries. Our objective was to create maps of four HIV indicators in North, Central, and South American countries.

Methods

Using data from the North American AIDS Cohort Collaboration on Research and Design (NA-ACCORD) and the Caribbean, Central, and South America network for HIV epidemiology (CCASAnet), we mapped median CD4 at presentation for HIV clinical care, proportion retained in HIV primary care, proportion prescribed antiretroviral therapy (ART), and the proportion with suppressed plasma HIV viral load (VL) from 2010 to 2012 for North, Central, and South America. The 15 Canadian and US clinical cohorts and 7 clinical cohorts in Argentina, Brazil, Chile, Haiti, Honduras, Mexico, and Peru represented approximately 2–7% of persons known to be living with HIV in these countries.

Results

Study populations were selected for each indicator: median CD4 at presentation for care was estimated among 14,811 adults; retention was estimated among 87,979 adults; ART use was estimated among 84,757 adults; and suppressed VL was estimated among 51,118 adults. Only three US states and the District of Columbia had a median CD4 at presentation >350 cells/mm³. Haiti, Mexico, and several states had >85% retention in care; lower (50–74%) retention in care was observed in the US West, South, and Mid-Atlantic, and in Argentina, Brazil, and Peru. ART use was highest (90%) in Mexico. The percentages of patients with suppressed VL in the US South and Northeast were lower than in most of Central and South America.

Conclusions

These maps provide visualization of gaps in the quality of HIV care and allow for comparison between and within countries as well as monitoring policy and programme goals within geographical boundaries.     

Global trends in testicular cancer incidence and mortality

Background

Epidemiologic studies on testicular cancer have focused primarily on European countries. Global incidence and mortality have been less thoroughly evaluated.

Objective

Our goal was to gain a better understanding of the most recent global age-standardized incidence and mortality rates for testicular cancer and to use these values to estimate a region's health care quality.

Design, setting, and participants

Age-standardized incidence rate (ASIR) and age-standardized mortality rate (ASMR) for testicular cancer were obtained for men of all ages in 172 countries by using the GLOBOCAN 2008 database, reflecting the annual rate of cancer incidence and mortality per 100 000 men. These data were evaluated on a regional level to compare incidence and mortality rates. Global plots of these values were constructed to better visualize geographic distributions. Finally, the ratio of ASIR to ASMR was calculated as a method to assess each region's proficiency in diagnosing and effectively treating testicular cancer.

Measurements

ASIR and ASMR were analyzed by region, and each region's ratio of ASIR to ASMR was calculated.

Results and limitations

Testicular cancer ASIR is highest in Western Europe (7.8%), Northern Europe (6.7%), and Australia (6.5%). Asia and Africa had the lowest incidence (<1.0%). ASMR was highest in Central America (0.7%), western Asia (0.6%), and Central and Eastern Europe (0.6%). Mortality was lowest in North America, Northern Europe, and Australia (0.1-0.2%). The ASIR-ASMR ratio was highest in Australia (65.0%) and lowest in western Africa (1.0%). National reporting systems varied by country, and data quality may have fluctuated between regions.

Conclusions

Testicular cancer incidence remains highest in developed nations with primarily Caucasian populations. Variable ASIR-ASMR ratios suggest markedly different geographic-specific reporting mechanisms, access to care, and treatment capabilities.     

Anemia and diabetes

World Health Organization statistics identify 150 million people with diabetes mellitus worldwide and suggest that this figure may double by 2025. In countries with a western lifestyle, the number of patients admitted for renal replacement therapy with diabetes as a co-morbid condition has increased significantly up to three to four times in a period of 10 years. Diabetes and renal failure are thus tightly linked diseases, and so is anemia. However, whether anemia may be worsened and/or directly, at least in part, caused by diabetes is not clearly elucidated yet. In this article, we review the prevalence, pathophysiology and consequences of anemia in diabetic patients.     

Diabetes in migrants and ethnic minorities in a changing World

On a worldwide scale, the total number of migrants exceeds 200 million and is not expected to reduce, fuelled by the economic crisis, terrorism and wars, generating increasing clinical and administrative problems to National Health Systems. Chronic non-communicable diseases(NCD), and specifically diabetes, are on the front-line, due to the high number of cases at risk, duration and cost of diseases, and availability of effective measures of prevention and treatment. We reviewed the documents of International Agencies on migration and performed a Pub Med search of existing literature, focusing on the differences in the prevalence of diabetes between migrants and native people, the prevalence of NCD in migrants vs rates in the countries of origin, diabetes convergence, risk of diabetes progression and standard of care in migrants. Even in universalistic healthcare systems, differences in socioeconomic status and barriers generated by the present culture of biomedicine make high-risk ethnic minorities under-treated and not protected against inequalities. Underutilization of drugs and primary care services in specific ethnic groups are far from being money-saving, and might produce higher hospitalization rates due to disease progression and complications. Efforts should be made to favor screening and treatment programs, to adapt education programs to specific cultures, and to develop community partnerships.     

Nephrology in Latin America,with special emphasis on Brazil

Latin America constitutes a complex universe that shows extreme variation regarding socioeconomic and human development. Brazil is the largest and most populous Latin American country, and combines characteristics encountered in developed countries with problems typically associated with the poorest regions of the world. These disparities condition the profile of renal disease in Brazil, with glomerulonephritis still the leading cause of ESRD. Little is known about the epidemiology of renal disease in the Brazilian (or Latin American) native population, which is numerous in some Central and South American countries, but constitute a very small minority in Brazil. However, interesting information has been obtained from the Yanomamis, a tribe living in Northern Brazil and Southern Venezuela. Hypertension is virtually absent among these people, who ingest very little sodium, lending strong support to the concept that sodium retention, a "civilization" factor, plays a role in the pathogenesis of arterial hypertension. Despite Brazil's striking socioeconomic disparities, access to RRT is in principle accessible to all those in need of it. The dialysis units have been modernized in recent years, whereas the Government covers most expenses related to RRT. However, the prevalence of RRT in Brazil is currently approximately 320 per million population, less than one third as high as in the US, suggesting that ESRD may be underdiagnosed in the country. Much effort is still needed to limit the prevalence of renal disease and to improve the quality and the reach of RRT in Brazil and in Latin America.     

Prevention of renal failure: the Malaysian experience

Renal replacement therapy in Malaysia has shown exponential growth since 1990. The dialysis acceptance rate for 2003 was 80 per million population, prevalence 391 per million population. There are now more than 10,000 patients on dialysis. This growth is proportional to the growth in gross domestic product (GDP). Improvement in nephrology and urology services with widespread availability of ultrasonography and renal pathology has improved care of renal patients. Proper management of renal stone disease, lupus nephritis, and acute renal failure has decreased these as causes of end-stage renal disease (ESRD) in younger age groups. Older patients are being accepted for dialysis, and 51% of new patients on dialysis were diabetic in 2003. The prevalence of diabetes is rising in the country (presently 7%); glycemic control of such patients is suboptimal. Thirty-three percent of adult Malaysians are hypertensive and blood pressure control is poor (6%). There is a national coordinating committee to oversee the control of diabetes and hypertension in the country. Primary care clinics have been provided with kits to detect microalbuminuria, and ACE inhibitors for the treatment of hypertension and diabetic nephropathy. Prevention of renal failure workshops targeted at primary care doctors have been launched, opportunistic screening at health clinics is being carried out, and public education targeting high-risk groups is ongoing. The challenge in Malaysia is to stem the rising tide of diabetic ESRD.     

Characteristics and comprehensiveness of adult HIV care and treatment programmes in Asia-Pacific,sub-Saharan Africa and the Americas: results of a site assessment conducted by the International epidemiologic Databases to Evaluate AIDS (IeDEA) Collaboration

Introduction

HIV care and treatment programmes worldwide are transforming as they push to deliver universal access to essential prevention, care and treatment services to persons living with HIV and their communities. The characteristics and capacity of these HIV programmes affect patient outcomes and quality of care. Despite the importance of ensuring optimal outcomes, few studies have addressed the capacity of HIV programmes to deliver comprehensive care. We sought to describe such capacity in HIV programmes in seven regions worldwide.

Methods

Staff from 128 sites in 41 countries participating in the International epidemiologic Databases to Evaluate AIDS completed a site survey from 2009 to 2010, including sites in the Asia-Pacific region (n=20), Latin America and the Caribbean (n=7), North America (n=7), Central Africa (n=12), East Africa (n=51), Southern Africa (n=16) and West Africa (n=15). We computed a measure of the comprehensiveness of care based on seven World Health Organization-recommended essential HIV services.

Results

Most sites reported serving urban (61%; region range (rr): 33–100%) and both adult and paediatric populations (77%; rr: 29–96%). Only 45% of HIV clinics that reported treating children had paediatricians on staff. As for the seven essential services, survey respondents reported that CD4+ cell count testing was available to all but one site, while tuberculosis (TB) screening and community outreach services were available in 80 and 72%, respectively. The remaining four essential services – nutritional support (82%), combination antiretroviral therapy adherence support (88%), prevention of mother-to-child transmission (PMTCT) (94%) and other prevention and clinical management services (97%) – were uniformly available. Approximately half (46%) of sites reported offering all seven services. Newer sites and sites in settings with low rankings on the UN Human Development Index (HDI), especially those in the President''s Emergency Plan for AIDS Relief focus countries, tended to offer a more comprehensive array of essential services. HIV care programme characteristics and comprehensiveness varied according to the number of years the site had been in operation and the HDI of the site setting, with more recently established clinics in low-HDI settings reporting a more comprehensive array of available services. Survey respondents frequently identified contact tracing of patients, patient outreach, nutritional counselling, onsite viral load testing, universal TB screening and the provision of isoniazid preventive therapy as unavailable services.

Conclusions

This study serves as a baseline for on-going monitoring of the evolution of care delivery over time and lays the groundwork for evaluating HIV treatment outcomes in relation to site capacity for comprehensive care.