Abstract
Abstract
Objective: To outline the process of making ‘good’ pharmaceutical policy decisions when faced with the emergence of an infectious disease. A retrospective study is presented which explores over a 40 year period, how policies emerged in Canada, Senegal, South Africa and the United States concerning the availability and accessibility of zidovudine (antiretrovirals) in the pharmacological management of human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) and compares the strategies used and resultant outcomes for each country to identify the timing and nature of strategies that worked.
Methods: An explanatory sequential mixed methods design compares the global AIDS policy evolution of Canada, Senegal, South Africa, and the United States over 40 years. These countries were selected based on their varying responses to the AIDS epidemic resulting in the following percentage of people living with HIV today: Canada (0.17%), the United States (0.33%), Senegal (0.26%), and South Africa (13%) (UNAIDS, 2018). A qualitative phase explored multiple data sources to construct a preliminary grounded theory. Emerging themes were used to design a survey and develop an interview protocol to further inform the theory and validate findings. Qualitative findings were categorized, coded using a content analysis approach and transformed into quantitative data. The quantitative data were analysed using descriptive statistics, incorporated into the theory, and member checked through the interview protocol. Finally, the extent to which the quantitative aspects validated and strengthened the theory of policy creation generated from the qualitative phase and what overall was learned in response to the study’s purpose was interpreted (Creswell et al., 2017).
Results: A purposive sample of 43 HIV/AIDS experts from the four countries were identified, with 18 (42%) responding and 12 completing interviews. The four countries studied were represented by the 12 expert interviews (5 U.S. experts, 3 South African experts, 2 Canadian experts and 2 experts who had worked in Senegal). Most of the experts stated that the timing of the government’s involvement in the epidemic impacted population health outcomes. Some stated that it was the early intervention from AIDS activists and the gay rights movement that influenced health outcomes. Early and rapid treatment programs occurred with the first effective drug therapy availability in the U.S. and Canada; and early prevention programs started in Senegal. These three countries demonstrate successful health outcomes today. Whereas South Africa took 20 years to implement a treatment program resulting in poor health outcomes. All respondents reported an expert opinion that early universal access to drug treatment is one of the most effective strategies for epidemic management. This conclusion was supported by the observed differences in the timing of the creation of treatment/prevention programs and associated infection rates in the four countries. All findings combined suggest that a multidimensional approach tailored to the type of economic development and existing societal structure within each country, implemented around the time the problem is identified, is needed to effectively manage infectious diseases.
Conclusions: The central phenomenon of the validated theory proposes that: 1) the early contextual translation of scientific evidence into policy combined with early implementation will result in improved health outcomes; and 2) the societal adoption of evidence-based practices and integration of evidence-based programs into healthcare delivery will result in healthier population-communities compared to those where these practices are not adopted. Seven global policy strategies and country strategies were identified that were consistent with improved health outcomes in the four-country comparison.
Keywords: HIV/AIDS, infectious disease, policy, grounded theory, mixed methods