Mapping health policies for optimum service delivery to adolescents on HIV treatment in Zambia: a document review

Abstract

Introduction

Despite significant advances in HIV treatment regimens, adolescents living with HIV (ALHIV) report lower rates of viral suppression compared to other age groups, reflecting sub-optimal adherence and lower engagement in care. In Zambia, adolescents lag behind in meeting the 95-95-95 targets for HIV care, when compared to adults. It is imperative that the specific needs of ALHIV are addressed in health policies that direct service delivery. This paper reports on Zambian health policies (policy documents and guidelines) that direct the provision of HIV care and treatment services for ALHIV, by assessing their alignment with recommendations for global best practice as presented in global health policies. We contextualize the policy review within the problem that exists in Zambia with respect to poor performance of the adolescents on the HIV cascade.

Methods

We conducted a document review of national health policies and guidelines (N = 10) that relate to HIV service delivery for ALHIV in Zambia and assessed these against the global health policies (N = 6) of which Zambia is a signatory using the four-step READ methodology for document review in health policy research. We used thematic content analysis to develop key themes that describe the components of health service delivery according to the World Health Organization’s (WHO) health systems framework, and comparative analysis to map national health policy against global health policies.

Results

The Zambian policies are aligned with global recommendations for health service delivery for ALHIV by including psychosocial support, peer support, mental health services and sexual and reproductive health education in their offering. In addition, Zambian health legislation advocates for a change in the age of consent for health services and comprehensive sexual education in schools, as globally recommended. However, there is a lack of deliberate involvement of adolescents, caregivers and community stakeholders in policy development. With respect to health financing, the national policies promote the integration of HIV financing with other health financing mechanisms but lack dedicated funding for adolescent HIV services. While community involvement is emphasised through youth advisory boards, training, and support groups, there is a notable absence of intentional adolescent engagement at the high-level program design stage.

Conclusions

Zambian health policies and guidelines align with global recommendations to optimize health service delivery for ALHIV in four of the six WHO Health Systems building blocks, as evidenced in the relevant global health policies. However, significant gaps remain in areas such as health legislation, financing and community engagement.

Introduction

Zambia’s health policies have increasingly recognized the unique challenges faced by adolescents, emphasizing the need for age-appropriate care and support systems. These policies aim to empower adolescents to engage with their health proactively, fostering a supportive environment for managing their HIV status [1]. Adolescents living with HIV (ALHIV) are increasingly acknowledged as a unique population with health needs that are distinct from children and adults [2]. This heightened recognition of the need for a differentiated health response is reflected in the World Health Organization’s (WHO) global strategy [3]. UNAIDS advocated for the Fast-Track goals of 95-95-95 [4] to ensure that 95% of all people living with HIV (PLHIV) know their HIV status; 95% of all PLHIV are initiated and retained on antiretroviral therapy (ART); and 95% of all PLHIV on ART are achieving viral suppression [5]. Whereas several sub-Saharan African countries, such as Botswana, Eswatini, Rwanda, Tanzania and Zimbabwe, have met these 95–95–95 targets for the general population in their respective countries [6], significant disparities exist across age cohorts, with a conspicuous lag among adolescents, aged 10–19 years [7]. In Zambia, the latest population-based HIV/AIDS impact assessment reveals that 88.7% of individuals aged 15 years and above are aware of their HIV status, and of these, 87% are receiving ART and 86% of them achieving viral suppression [8]. However, even lower rates of viral suppression are reported for adolescents and young people (AYP) (aged 15–24 years): 72.8% are aware of their HIV status, with only 71.7% receiving ART, and 66.6% of those on ART attaining viral suppression [9]. It is widely reported that ALHIV encounter significant impediments in attaining viral suppression [10, 11] which is associated with suboptimal adherence and high loss to follow-up [12,13,14]. National health policies play a critical role in the attainment of the Fast-Track goals, because they impact on clinical and treatment guidelines, health service delivery, as well as the provision of psychosocial and community-based support services to optimize treatment outcomes for ALHIV [15]. A comprehensive, enabling health policy environment is essential to meet the unique health service delivery challenges encountered by ALHIV [16]. Global health policies encapsulate and propagate for the adoption of widely established global recommendations to address adolescent-specific needs for care and support services [17]. In the absence of adequate policy support, ALHIV encounter barriers to accessing HIV testing, treatment and care services, which in turn, result in delayed diagnosis, poor treatment adherence, and increased risk of disease progression and transmission [18]. Globally, it is suggested that individual countries should examine existing laws and policies to identify and address age-related barriers that hinder access to and utilization of services established under these provisions [18, 19]. Aligning Zambia’s health policy with global policies ensures the adoption of best practices, improves healthcare quality and efficiency and leads to better health outcomes.

This paper aims to evaluate the alignment of Zambia’s health policies with global recommendations for ALHIV. In this study, the term “policy” collectively refers to all national Zambian health policies and guidelines.

Methods

Study design

We followed the four-step READ methodology for document review in health policy research [20]. The first step, ‘Ready your materials’, entailed developing a search strategy and eligibility criteria to identify relevant policy documents for analysis. The second step, ‘Extract data’, involved organizing essential information from identified documents, such as foundational data and key concepts. The third step, ‘Analyse data’, focused on interpreting data and generating findings from the analysis. Finally, the fourth step, ‘Distil your findings’, required evaluating the adequacy of the data for addressing the purpose of the study and refining findings into a cohesive narrative.

Search strategy

We performed an iterative internet search to locate policy and guideline documents available in the public domain, accessible at www.moh.gov.zm and a general internet search of multilateral organization documents of which Zambia is a signatory.

We used the following keywords in our search strategy: “Adolescents”; “Guidelines for Adolescents Living with HIV”; “adolescent health”; “adolescent HIV/AIDS Policy”; “antiretroviral therapy”; “youth and HIV”; “WHO Antiretroviral therapy guidelines”; “UNAIDS 95-95-95”; “UNICEF and adolescents living with HIV”; and “Zambia”.

Eligibility criteria

Official health policies and guidelines published by Zambia’s MOH, or health policies or guidelines from international organizations to which Zambia is a signatory were included if they address health service delivery and apply to the Zambian context.

The search period was limited to documents published between 2016 and 2023; due to significant guideline changes recommended by the WHO in their clinical and operational guidelines released in 2015 [21, 22].

Eligibility of the retrieved documents was verified according to the criteria for authenticity, reliability, representativeness and relevance of the data [23]. The first reviewer (KM) conducted the search and presented the list of eligible documents for verification by a second reviewer (BVW). Documents were included if there is consensus between the two reviewers. The final list of included documents was presented to the third reviewer (TC) for approval.

The document selection process is illustrated in Fig. 1. The final analysis included 16 documents: two global health policies and four guideline documents; and four national policies and six guideline documents (Table 1).

Fig. 1

Flowchart of document selection process: adapted from reference [24]

Table 1 Global policy and program document measures for optimizing service delivery for ALHIV

Data extraction process

We developed a Microsoft Word data extraction sheet to ensure consistency in the process of data extractions across all policy documents. Afterwards, the identified policy documents were gathered and reviewed to understand their content through an iterative process between the first researcher (KM) and a second researcher (BVW). The key information was summarised with the following headings: Document type; Title; Year of Publication; Developers; Purpose/Aim; Recommendations for improving HIV treatment outcomes for adolescents (see Table 1). To foster quality assurance, one researcher extracted the data, while the other two researchers checked for errors, ensured accuracy and consistency, and provided feedback. All researchers reached a consensus on the final dataset.

Data analysis

We applied thematic content analysis to develop themes as described by Lincoln and Guba [30]. We familiarised ourselves with the policy documents, generated initial codes, grouped the codes into themes and drafted the analysis in a structured format (Tables 1 and 2). Lincoln and Guba’s criteria guided the process by ensuring that the interpretation of policy documents is credible and accurately reflects their content. Dependability was maintained through systematic coding and analysis procedures that ensured consistent in identifying theme identification across policy texts. Confirmability was also established through reviewer reflexivity [30]. Two reviewers (KM and BVW) developed a coding scheme and coded the extracted data and organised it into themes and subthemes, which were then confirmed by a third reviewer (TC). The themes are described for each policy/guideline in summary of the content of the policy, as seen in Table 1. Using the WHO health systems framework, we mapped out global recommendations for optimizing service delivery to ALHIV from the global policies (Fig. 2). In this analysis, we regarded the global health policies and guidelines as the standard practice, and therefore also applicable in Africa. Four (of the six) blocks of the WHO health systems framework were evident in the global policies, namely: (i) health service delivery, (ii) health policy legislation; (iii) health financing and, (iv) community involvement [31]. The recommendations from the global policies and guidelines were then grouped as sub-themes under each health system block (theme). The other two blocks, namely, Medical products, vaccines and technologies, and Health information systems were not evident in the global health policies that we reviewed.

Table 2 Zambian policy and guidelines for service delivery for ALHIV

Fig. 2

Scoring Zambian policies on adolescents and HIV treatment against global policy and recommendations

We scored the content of national policies and guidelines against globally recommended best practices by utilizing a customized scorecard with a traffic light color scheme (Fig. 2). Themes that denote national policies that were tailored to ALHIV, and in keeping with global recommendations, were scored as “Green” - which signified intentional alignment. Where themes in national policies either do not feature in national guidelines, or they lack specificity regarding ALHIV, we scored these as “Orange” – which signified incidental alignment. Where there was complete absence or no uptake of specific global recommendations in national policies, we scored these themes as “Red” – which indicate no alignment.

Results

Sixteen policies and guidelines were included in the review, of which six were global (including two policies and four guidelines) (Table 1) and 10 national (comprising four policies and six guidelines), as outlined in Table 2. All national policies and guidelines were developed by the National Ministry of Health, Zambia; with some collaborations with civil society (n = 4) and international development partners (n = 10) and non-governmental organizations (n = 9). Contributions to some Zambian policies and guidelines were obtained from adolescents and young people (AYP) (n = 1) and peer educators (n = 2). These policies and guidelines tend to group children and adolescents living with HIV (CALHIV) (n = 5), aged 0–19 years, AYP (n = 4) aged 10–24 years, with one specific to adolescents aged 10–19 years.

Health services delivery

As illustrated in Fig. 2, Zambian health policies align intentionally with global recommendations for health service delivery for ALHIV to include psychosocial support, peer support for adherence and retention, mental health services, sexual and reproductive health (SRH) education, optimized ARV regimens, and differentiated service delivery models for ALHIV.

Zambian health policy placed high premium on the provision of psychosocial support for ALHIV as reflected in two national policies [33, 34] and five guidelines [36,37,38,39,40]. Three policies [1, 32, 33] and four guidelines [36, 37, 39, 40] advocate for the application of peer support strategies such as health education for behaviour change, peer groups and peer outreach to improve adherence and retention of ALHIV on ART (Table 2). The Zambian policy is clear and intentional on addressing the mental and emotional well-being of ALHIV [37]. Further, three policies [33, 34] and two guidelines [35, 37] recommend comprehensive SRH education for adolescents. The national ART clinical guidelines [35] is aligned with global recommendations for best practice [41] in advocating for timely switching of eligible ALHIV to dolutegravir (DTG) as a more efficacious first-line regimen [42]. Zambia has further adopted differentiated service delivery (DSD) models for treatment of adolescents and young people (AYP) as described in two policies [1, 33] and five guidelines [35,36,37, 39, 40]. The models include a Family Centred Care Model, Scholars Model, Mobile ART Distribution Model, Home ART Delivery at the community level and Fast track, multi-month dispensing, transitioning treatment clubs, and Before/After-hours/Weekend Clinics at the facility level (Table 2).

Health policy legislation

Zambian health policy follows global recommendations to revise the age of consent to access health services, advocate for laws that mandate comprehensive sexual education in schools and inclusion of adolescents, caregivers, and community stakeholders in the development of health policies related to HIV. One policy explicitly and intentionally addresses the issue of the legal age of consent for accessing health services, particularly SRH and HIV care [33]. A review of policy and regulatory frameworks for the provision and access of adolescent health services facilitates identification of gaps towards improving access to comprehensive care tailored to their needs, promoting informed decision-making, reducing stigma, and enhancing health outcomes (see Table 2). Additionally, two polices [1, 33] and one guideline [39] advocate for laws that mandate comprehensive sexual education in schools. Two guidelines mention stakeholder engagement with one intentional to the involvement of ALHIV in the development of the guideline [39], while the other outlines community stakeholder participation in development but not specific to ALHIV [35].

Health financing

Global policies and guidelines recommend dedicated funding for adolescent-specific services and health worker training, integrating HIV funding streams with other health financing mechanisms to ensure a comprehensive approach to adolescent healthcare, and advocating for health insurance policies that address the unique needs of ALHIV; however, Zambian specific policies and guidelines contrast, lacking dedicated ring-fenced financing for adolescent-specific services, comprehensive health worker training provisions, and supportive health insurance policies that address the unique needs of ALHIV. Two Zambian policies intentionally and specifically outline integration of HIV funding streams with other health financing mechanisms to ensure a comprehensive approach to adolescent healthcare [1, 32]. This is to be done through government funding and mobilization of resources through implementing partners (NGOs) supporting government efforts in the fight against HIV/AIDS (see Table 2).

Community involvement

Global policies and guidelines recommend high-level involvement of community members in health program design, establishment of youth advisory boards, training, and capacity building of community members, including youth, caregivers, and local leaders, and formation of community-based support groups. Similarly, two Zambian policies [1, 32] and one guideline [35] intentionally recommend the training and capacity building of adolescents and caregivers. This plays a critical role in improving health outcomes, reducing stigma, promoting adherence to treatment, and fostering supportive environments for ALHIV to thrive (see Table 2). In alignment with global recommendations, two Zambian policies [1, 33] and one guideline [39] promote the formation of support groups which provide invaluable emotional, informational, and social support, and empower ALHIV to better cope with the challenges of HIV and AIDS (see Table 2). Additionally, one Zambian guideline [35] recommends the formation of adolescent/youth advisory groups which provide valuable insights, perspectives, and recommendations from the adolescent perspective, ensuring that programs are tailored to meet the specific needs, preferences, and realities of ALHIV affected by HIV and AIDS [43]. These groups empower youth to actively participate in decision-making processes, advocate for their rights and interests, and contribute to the development, implementation, and evaluation of HIV prevention, treatment, and care initiatives [43]. Two Zambian policies [32, 33] incidentally talk about community engagement with no intentional mention of adolescents (see Table 2) as per global recommendations.

Discussion

This study systematically evaluated the alignment of Zambian health policies and guidelines for ALHIV against global recommendations, revealing both significant gaps in policy implementation and notable areas of alignment, which collectively underscore the need for targeted policy reforms while also recognising existing efforts to address the unique healthcare requirements of ALHIV.

Our review identified policies and guidelines that addressed the needs of ALHIV under the Health Services Delivery pillar. The policies and guidelines to a great extent address psychosocial support services [32, 34, 36,37,38,39,40], peer support strategies [1, 32, 33, 36, 37, 39, 40] for adherence and retention, screening and referral of ALHIV to/for mental health services [37], SRH education and services [24, 30, 36, 40], optimised ART regimens [35] and differentiated service delivery models [33, 35,36,37, 39, 40] under the health services delivery pillar. This suggests that Zambia is intentional and deliberate on its policy approach and guidelines to improve health service delivery, and shows a clear commitment to providing adolescent-friendly and tailored services for this population. The results of this review show similarities with countries in Southern Africa. Similar to Zambia, South Africa and Malawi, are intentional to health service delivery in relation to psychosocial support services, sexual and reproductive health, mental health, optimized ART regimens for eligible ALHIV, peer support strategies for adherence and retention and differentiated service delivery models [44,45,46,47,48]. However, mental health services are not widely available for AYP who often lack comprehensive youth friendly services in Botswana [49]. Botswana, South Africa and Namibia further align with the Zambian guidelines in relation to optimization of ART regimens for eligible ALHIV and psychosocial support services [44, 50, 51].

Across the documents reviewed, Zambia’s policy and guidelines direction is both intentional and incidental within the Health Policy Legislation pillar. The policies and guidelines intentionally address change in age of consent to access health services and advocate for laws that mandate comprehensive sexual education in schools [24, 34, 37]. This aligns with policies from Namibia and South Africa which promote comprehensive sexual education and advocate for changes in age of consent for health services [46, 52]. However, the inclusion of adolescents, caregivers, and community stakeholders in the development of health policies related to HIV is not deliberately mentioned for adolescents and therefore incidental. This is in contrast to the South African National Strategic Plan for HIV, Tuberculosis, Sexually Transmitted Infections 2023–2028 which intentionally and deliberately outlines the involvement of all stakeholders in policy and guideline development with adolescents intentionally mentioned [46].

Within the Health Financing pillar, documents reviewed indicate that Zambia, like other countries such as Botswana, Namibia, and Malawi is intentional in the integration of HIV funding streams with other health financing mechanisms to ensure a comprehensive approach to adolescent healthcare [48, 49, 53]. However, unlike South Africa’s National Youth Policy, which intentionally provides for dedicated funding to support adolescent and youth programmes, there is an absence of dedicated funding for adolescent-specific programmes in Zambian policies; with adolescent programs currently receiving funding within the broader health basket funding but not as a distinct, ring-fenced allocation [45]. In all documents reviewed, advocacy for health insurance policies that cover the unique needs of ALHIV was absent. This is similar to other countries (Botswana, Namibia, Malawi) in the region where all documents reviewed, including policies and guidelines were missing this component.

Community involvement was a common theme in most documents reviewed showing that Zambia is intentional in this regard. The intentional recommendation for training and capacity building of ALHIV and caregivers, as highlighted in two national policies [1, 32] and one guideline [35], represents a pivotal step towards optimising service delivery and health outcomes among ALHIV. This is consistent with findings in policies and guidelines from South Africa, Namibia, and Malawi [45,46,47]. Furthermore, the promotion of support group formation, emphasised in two policies [1, 33] and one guideline [39], underscores the recognition of the invaluable role that peer support plays in the lives of ALHIV. Similar findings are found in documents for South Africa where emphasis on peer support is deliberate [46]. The recommendation for the establishment of adolescent/youth advisory groups, as outlined in one guideline [35], represents a significant stride towards ensuring that programs are tailored to meet the specific needs and preferences of ALHIV. This is similar to findings in the South Africa National Youth Policy which intentionally advocates for adolescent’s involvement in advisory groups [45]. However, it is notable that while community engagement is emphasized in two policies [32, 33], it is only incidental to ALHIV. This highlights a potential gap in current policies, suggesting the need for more explicit recognition of the unique needs and perspectives of ALHIV within community engagement initiatives.

Limitations

The limitation of this paper is that it is based only on the review of policies and guidelines with no direct engagement with policy makers, stakeholders or affected communities who could provide valuable insights, perspectives or feedback that could inform the policy and guideline review process. The current paper reports on the intentions of the Zambian national Ministry of Health as reflected in published policies and guidelines; which may not necessarily translate into practice on the various health services levels.

Conclusion

It is evident that the current national polices and guidelines are comprehensively aligned to global recommendations for the provision of HIV care and treatment services to ALHIV in Zambia. Health service delivery was intentionally aligned across all services while health policy legislation, health financing and community involvement showed areas which were intentional, incidental and no uptake. We thus recommend that areas falling short of alignment be considered during future policy and guidelines reviews.