Decentralising HIV treatment in lower- and middle-income countries

Abstract

BACKGROUND: Policy makers, health staff and communities recognise that health services in lower-and middle-income countries need to improve people's access to HIV treatment and retention to treatment programmes. One strategy is to move antiretroviral delivery from hospitals to more peripheral health facilities or even beyond health facilities. This could increase the number of people with access to care, improve health outcomes, and enhance retention in treatment programmes. On the other hand, providing care at less sophisticated levels in the health service or at community-level may decrease quality of care and result in worse health outcomes. To address these uncertainties, we summarised the research studies examining the risks and benefits of decentralising antiretroviral therapy service delivery. OBJECTIVES: To assess the effects of various models that decentralised HIV treatment and care to more basic levels in the health system for initiating and maintaining antiretroviral therapy. METHODS:Search methods: We conducted a comprehensive search to identify all relevant studies regardless of language or publication status (published, unpublished, in press, and in progress) from 1 January 1996 to 31 March 2013, and contacted relevant organisations and researchers. The search terms included "decentralisation", "down referral", "delivery of health care", and "health services accessibility". Selection criteria: Our inclusion criteria were controlled trials (randomised and non-randomised), controlled-before and after studies, and cohorts (prospective and retrospective) in which HIV-infected people were either initiated on antiretroviral therapy or maintained on therapy in a decentralised setting in lower-and middle-income countries. We define decentralisation as providing treatment at a more basic level in the health system to the comparator. Data collection and analysis: Two authors applied the inclusion criteria and extracted data independently. We designed a framework to describe different decentralisation strategies, and then grouped studies against these strategies. Data were pooled using random-effects metaanalysis. Because loss to follow up in HIV programmes is known to include some deaths, we used attrition as our primary outcome, defined as death plus loss to follow-up. We assessed evidence quality with GRADE methodology. MAIN RESULTS: Sixteen studies met the inclusion criteria, all but one were from Africa, comprising two cluster randomised trials and 14 cohort studies. Antiretroviral therapy started at a hospital and maintained at a health centre (partial decentralisation) probably reduces attrition (RR 0.46, 95% CI 0.29 to 0.71, 4 studies, 39 090 patients, moderate quality evidence). There may be fewer patients lost to care with this model (RR 0.55, 95% CI 0.45 to 0.69, low quality evidence). We are uncertain whether there is a difference in attrition for antiretroviral therapy started and maintained at a health centre (full decentralisa-

Treatment retention and care transitions during and after the scale-up of HIV care and treatment in Northern Tanzania

“…A recent Cochrane review (Kredo, Ford, Adeniyi, & Garner, 2013) provided no evidence that decentralization from hospitals to more peripheral health facilities led to worse health outcomes, and in some settings loss to care was reduced. However, experiences from both wealthier and poorer nations suggest that the quality of HIV care varies greatly across diverse HIV treatment clinics (Halm, Lee, & Chassin, 2002; T.…”

Discontinuation from Antiretroviral Therapy: A Continuing Challenge among Adults in HIV Care in Ethiopia: A Systematic Review and Meta-Analysis

“…This finding was not a surprise as could be attributed to factors such as accessibility of the health care and availability of the transportation services[41,42]. It is therefore, plausible to hypothesise that strengthening decentralization and service integration of HIV care in remote areas would be a key for patient retention[43]. This hypothesis is also currently supported by WHO recommendations[44] of task shifting.…”

Community-Based Interventions to Improve and Sustain Antiretroviral Therapy Adherence, Retention in HIV Care and Clinical Outcomes in Low- and Middle-Income Countries for Achieving the UNAIDS 90-90-90 Targets

“…In building decentralized ART delivery, adherence, and retention in care support, community-based ART programs encourage patient autonomy, build social networks, and minimize the structural barriers, such as cost of transport to the clinic, which in turn appear to result in better outcomes [69]. Such community-based interventions are likely to have more impact since they tend to involve trained community health workers, peers, volunteers, or patient’s own social network members (e.g., family and friends) who assist with ART adherence counseling and support.…”