Successful clinical outcomes following decentralization of tertiary paediatric HIV care to a community‐based paediatric antiretroviral treatment network, Chiangrai, Thailand, 2002 to 2008

Abstract

IntroductionMost paediatric antiretroviral treatments (ARTs) in Thailand are limited to tertiary care hospitals. To decentralize paediatric HIV treatment and care, Chiangrai Prachanukroh Hospital (CRH) strengthened a provincial paediatric HIV care network by training community hospital (CH) care teams to receive referrals of children for community follow-up. In this study, we assessed factors associated with death and clinical outcomes of HIV-infected children who received care at CRH and CHs after implementation of a community-based paediatric HIV care network.MethodsClinical records were abstracted for all children who initiated ART at CRH. Paired Wilcoxon signed rank tests were used to assess CD4% and virological change among all children. Cox proportional hazard models were used to assess factors associated with death. Treatment outcomes (CD4%, viral load (VL) and weight-for-age Z-score (WAZ)) were compared between CRH and CH children who met the criteria for analysis.ResultsBetween February 2002 and April 2008, 423 HIV-infected children initiated ART and 410 included in the cohort analysis. Median follow-up for the cohort was 28 months (interquartile range (IQR)=12 to 42); 169 (41%) children were referred for follow-up at CH. As of 31 March 2008, 42 (10%) children had died. Baseline WAZ (<−2 (p=0.001)) and baseline CD4% (<5% (p=0.015)) were independently associated with death. At 48 months, 86% of ART-naïve children in follow-up had VL<400 copies/ml. For sub-group analysis, 133 children at CRH and 154 at CHs were included for comparison. Median baseline WAZ was lower in CH children than in CRH children (p=0.001); in both groups, WAZ, CD4% and VL improved after ART with no difference in rate of WAZ and CD4% gain (p=0.421 and 0.207, respectively).ConclusionsChildren at CHs had more severe immunological suppression and low WAZ at baseline. Community- and tertiary care-based paediatric ART follow-ups result in equally beneficial outcomes with the strengthening of a provincial referral network between tertiary and community care. Nutrition interventions may benefit children in community-based HIV treatment and care.

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

“…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).…”

From Transmission to Transition: Lessons Learnt from the Thai Paediatric Antiretroviral Programme

“…In Thailand they are a recognized part of the strategy to ensure long-term psychosocial support in HIV care [19], [30]. Our assessment highlights the need for providers to develop broader skills to cope with the ever-changing physical and psychosocial burden of HIV infection in a vulnerable population with relatively weak support structures.…”

Short-term outcomes of down-referral in provision of paediatric antiretroviral therapy at Red Cross War Memorial Children’s Hospital, Cape Town, South Africa: A retrospective cohort study

“…[16] This perfect retention in care can be attributed to the intensive support and adherence counselling provided after down-referral, with ongoing involvement of the referral team, who provided active mentorship and clinical support to the treating teams in the community hospitals as well as 6-monthly clinical reviews of the down-referred children at the tertiary referral hospital. [16] In contrast, the support available in our study was much less intensive, consisting of telephonic support for clinicians caring for HIV-infected children at the PHC clinics, and monthly clinical mentoring visits by an infectious diseases subspecialist from RCWMCH.…”

“…Greater attention should be given to monitoring down-referred children and strengthening the support provided to them and their caregivers. While the level of support given to down-referred children in the Thai study [16] is perhaps unrealistic in the SA context, more formalised communications with referral sites and telephonic contact tracing of patients after down-referral is feasible. Furthermore, community adherence support has been shown to improve retention in care of children on ART in the SA public sector and should be considered for caregivers of children down-referred to community clinics on ART.…”