Decentralization of Pediatric HIV Care and Treatment in Five Sub-Saharan African Countries

Fayorsey, Ruby; Saito, Suzue; Carter, Rosalind J.; Gusmão, Eduarda Pimentel De; Frederix, Koen; Koech-Keter, Emily; Tene, Gilbert; Panya, Milembe; Abrams, Elaine J.

doi:10.1097/qai.0b013e3182869558

Cited by 53 publications

(56 citation statements)

References 26 publications

(38 reference statements)

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“…G. Heckman et al, 1998; Hogg et al, 1998; Shapiro et al, 1999). While some studies indicate that comparable quality can be provided at primary health facilities (Boyer et al, 2012; Fayorsey et al, 2013; Hansudewechakul et al, 2012; McGuire et al, 2012), others document a lack of laboratory facilities, medication shortages and limited drug options (Labhardt et al, 2012; Nyogea et al, 2012; Pasquet et al, 2010). Further, while some aspects of localized care, such as community-based support and increased tracing of defaulters, may appeal to some patients, others may perceive these activities as intrusive or stigmatizing (Humphreys et al, 2010).…”

Section: Discussionmentioning

confidence: 99%

“…Decentralization of HIV care has been pursued by numerous sub-Saharan African (SSA) countries (see, e.g., Fayorsey et al, 2013; Pfeiffer et al, 2010; Topp et al, 2013; Uebel, Joubert, Wouters, Mollentze, & van Rensburg, 2013; World Health Organization, 2013) and is advocated by the President’s Emergency Plan for AIDS Relief (PEPFAR) as a means of expanding coverage, co-utilizing services for HIV and other illnesses, and improving engagement and retention in care (PEPFAR, 2009; Gilks et al, 2006; Mulamba et al, 2010). While several implementation studies (Mutemwa et al, 2013; Topp et al, 2013; Uebel et al, 2013) described efficiency gains due to decentralization and integration of HIV care with care for other conditions, little is known about changes in patients’ care-seeking behaviors in response to the availability of additional treatment options.…”

Section: Introductionmentioning

confidence: 99%

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

et al. 2014

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Decentralization of HIV care is promoted to improve access to antiretroviral therapy in sub-Saharan Africa. This study describes care transitions among HIV-infected persons in Northern Tanzania during a period of rapid decentralization of HIV Care and Treatment Centers (CTCs) from hospitals to local health centers. Between November 2008 and June 2009, 492 HIV-infected patients in established care at two referral hospitals in Moshi, Tanzania, and 262 persons newly diagnosed with HIV were selected for participation in a prospective cohort study entitled Coping with HIV/AIDS in Tanzania. Clinical records and participant self-reports, collected between June and November 2012, were used to describe retention in care and transitions between CTCs during the study period. After a mean follow-up period of 3.5 years, 10 percent of participants had died, 9 percent were lost to follow-up, and 11 percent had moved. Of the remaining participants enrolled from CTCs, more than 90 percent reported at least one CTC visit during the previous six months, with 98 percent still in care at the CTC at which they were enrolled. Nearly 3 out of 4 newly diagnosed clients listed a referral hospital as their primary CTC. Fewer than 10 percent of participants ever sought care at another CTC in the study area; nearly 90 percent of those in care bypassed their closest CTC. Administrative data from all facilities in the study area indicate that new clients, even after the scale-up from 8 CTCs in 2006 to 21 CTCs in 2008, disproportionately selected established CTCs, and client volume at newly approved facilities was highly variable. Despite the decentralization of HIV care and treatment in this setting, many patients continue to bypass their closest CTC to seek care at established facilities. Patient preferences for HIV care, which may inform optimal resource utilization, are largely unknown and warrant further investigation.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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

et al. 2014

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“…Numerous studies conducted in sub-Saharan Africa have assessed the impact of selected structural changes, such as task-shifting and decentralization of services, on HIV treatment outcomes. [12]–[17] Process indicators capturing key services, such as semi-annual CD4 count monitoring, routine opportunistic infection screening and regular adherence support, are frequently collected for programmatic monitoring and evaluation. However, the correlation between process indicators such as these and clinical outcomes of HIV care and treatment has not been well explored in resource limited settings.…”

Section: Introductionmentioning

confidence: 99%

The Association between Quality of HIV Care, Loss to Follow-Up and Mortality in Pediatric and Adolescent Patients Receiving Antiretroviral Therapy in Nigeria

et al. 2014

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Access to pediatric HIV treatment in resource-limited settings has risen significantly. However, little is known about the quality of care that pediatric or adolescent patients receive. The objective of this study is to explore quality of HIV care and treatment in Nigeria and to determine the association between quality of care, loss-to-follow-up and mortality. A retrospective cohort study was conducted including patients ≤18 years of age who initiated ART between November 2002 and December 2011 at 23 sites across 10 states. 1,516 patients were included. A quality score comprised of 6 process indicators was calculated for each patient. More than half of patients (55.5%) were found to have a high quality score, using the median score as the cut-off. Most patients were screened for tuberculosis at entry into care (81.3%), had adherence measurement and counseling at their last visit (88.7% and 89.7% respectively), and were prescribed co-trimoxazole at some point during enrollment in care (98.8%). Thirty-seven percent received a CD4 count in the six months prior to chart review. Mortality within 90 days of ART initiation was 1.9%. A total of 4.2% of patients died during the period of follow-up (mean: 27 months) with 19.0% lost to follow-up. In multivariate regression analyses, weight for age z-score (Adjusted Hazard Ratio (AHR): 0.90; 95% CI: 0.85, 0.95) and high quality indicator score (compared a low score, AHR: 0.43; 95% CI: 0.26, 0.73) had a protective effect on mortality. Patients with a high quality score were less likely to be lost to follow-up (Adjusted Odds Ratio (AOR): 0.42; 95% CI: 0.32, 0.56), compared to those with low score. These findings indicate that providing high quality care to children and adolescents living with HIV is important to improve outcomes, including lowering loss to follow-up and decreasing mortality in this age group.

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“…[6][7][8][9][10][11] Most information on ART scale-up focuses on adults, although lower mortality and LTFU have also been reported with successful ART rollout to children. 12,13 Decentralisation has been shown to be beneficial especially to poorer individuals and those living in rural areas who are less likely to access HIV testing and treatment services due to the distance to facilities and transport costs. [14][15][16] The Lablite project investigated strategies for cost-effective and safe roll out of HIV treatment to primary health facilities in Uganda, Malawi and Zimbabwe in collaboration with respective ministries of health.…”

Section: Introductionmentioning

confidence: 99%

Impact of decentralisation of antiretroviral therapy services on HIV testing and care at a population level in Agago District in rural Northern Uganda: results from the Lablite population surveys

Abongomera

Kiwuwa-Muyingo

Revill

et al. 2017

International Health

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Background: We conducted unlinked cross-sectional population-based surveys in Northern Uganda before and after antiretroviral therapy (ART) provision (including Option B+ [lifelong ART for pregnant/breast-feeding women]) at a local primary care facility (Lira Kato Health Centre [HC]). Prior to decentralisation, people travelled 56-76 km round-trip for ART; we aimed to evaluate changes in uptake of HIV-testing, ART coverage and access to ART following decentralisation.Methods: A total of 2124 adults in 1351 households in two parishes closest to Lira Kato HC were interviewed using questionnaires between March and April 2013 and 2123 adults in 1229 households between January and March 2015.Results: Adults reporting HIV-testing in the last year increased from 1077/2124 (50.7%) to 1298/2123 (61.1%) between surveys (p<0.001). ART coverage increased from 74/136 (54.4%) self-reported HIV-positive adults in 2013 to 108/133 (81.2%) in 2015 (p<0.001). Post-decentralisation, 47/108 (43.5%) of those on ART were in care at Lira Kato HC (including 37 new initiations). Most of the remainder (47/61, 77%) started ART prior to any ART provision at Lira Kato HC; the most common reason given for not accessing ART locally was concern about drug-stock-outs (30/59, 51%).Conclusions: HIV-testing and ART coverage increased after decentralisation combined with Option B+ roll-out. However, patients on ART before decentralisation were reluctant to transfer to their local facility.

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Decentralization of Pediatric HIV Care and Treatment in Five Sub-Saharan African Countries

Abstract: The expansion of pediatric services to PHFs has resulted in increased numbers of children on ART. Early findings suggest lower rates of LTFU and mortality at PHFs. Successful scale-up will require further expansion of pediatric services within PHFs.

Cited by 53 publications

References 26 publications

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

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

The Association between Quality of HIV Care, Loss to Follow-Up and Mortality in Pediatric and Adolescent Patients Receiving Antiretroviral Therapy in Nigeria

Impact of decentralisation of antiretroviral therapy services on HIV testing and care at a population level in Agago District in rural Northern Uganda: results from the Lablite population surveys

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