Treatment Initiation, Program Attrition and Patient Treatment Outcomes Associated with Scale-Up and Decentralization of HIV Care in Rural Malawi

McGuire, Megan; Pinoges, Loretxu; Kanapathipillai, Rupa; Munyenyembe, Tamika; Huckabee, Martha; Makombe, Simon D; Szumilin, Elisabeth; Heinzelmann, Annette; Pujades-Rodríguez, Mar

doi:10.1371/journal.pone.0038044

Cited by 32 publications

(35 citation statements)

References 35 publications

(37 reference statements)

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“…None of the studies evaluated ART coverage. All studies reported improved retention in care [45][46][47][48] (overall estimate RR 1.12, 95% CI 1.08-1.17, Figs 4 and 5). Three studies reported reduced mortality [46][47][48], although one estimate lacked statistical significance [47], whereas one study reported increased mortality [45] (Fig.…”

Section: Full Decentralization Of Antiretroviral Therapymentioning

confidence: 96%

Improving antiretroviral therapy scale-up and effectiveness through service integration and decentralization

Suthar

Rutherford²,

Horváth³

et al. 2014

AIDS

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Integrating ART into MNCH, TB, and OST services was often associated with improvements in ART coverage, and decentralization of ART into primary health facilities and communities was often associated with improved retention. Neither integration nor decentralization was associated with adverse outcomes. These data contributed to recommendations in the WHO 2013 consolidated antiretroviral guidelines to integrate ART delivery into MNCH, TB, and OST services and to decentralize ART.

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Section: Full Decentralization Of Antiretroviral Therapymentioning

confidence: 96%

Improving antiretroviral therapy scale-up and effectiveness through service integration and decentralization

Suthar

Rutherford²,

Horváth³

et al. 2014

AIDS

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“…One study had a prospective cohort design (Sangsari et al, 2012), and eight studies did not explicitly state their design strategy. Most of the studies had taken place in the USA (n = 12) (Anaya et al, 2004;Backus et al, 2010;Chu et al, 2010;Horberg et al, 2007;Kerr et al, 2012;Kitahata et al, 2003;Landon et al, 2005;Rodriguez, Marsden, Landon, Wilson, & Cleary, 2008;Saha et al, 2013;Solomon et al, 2005;Wilson, Landon, Hirschhorn, et al, 2005) and countries in sub-Saharan Africa (n = 13) (Assefa et al, 2012;Balcha & Jeppsson, 2010;Boyer et al, 2010Boyer et al, , 2011Chan et al, 2011;Ekouevi et al, 2012;Fatti et al, 2010;Fatti, Grimwood, Mothibi, & Shea, 2011;McGuire et al, 2012;Odafe, Idoko, et al, 2012;Odafe, Torpey, et al, 2012;Reidy et al, 2014;Sherr et al, 2010). The remaining studies were situated in Brazil (Nemes et al, 2009), India (Shet et al, 2011), and Canada (Sangsari et al, 2012) (Figure 1).…”

Section: Resultsmentioning

confidence: 99%

“…There was no difference in virologic success among patients in care in centralized (hospital-based) versus decentralized (community-based) facilities (Chu et al, 2010;McGuire et al, 2012) (the USA and Malawi). In one study, patients treated in private health facilities were more likely to have treatment failure compared to patients in public/public-private health facilities (India) (Shet et al, 2011).…”

Section: <400mentioning

confidence: 98%

“…These studies assessed the impact of private versus public funding (Boyer et al, 2011;Ekouevi et al, 2012;Shet et al, 2011), level of care (primary/secondary/tertiary; hospital/clinic; or centralized/decentralized) (Assefa et al, 2012;Balcha & Jeppsson, 2010;Boyer et al, 2010Boyer et al, , 2011Chan et al, 2011;Ekouevi et al, 2012;Fatti et al, 2010;McGuire et al, 2012;Odafe, Idoko, et al, 2012;Odafe, Torpey, et al, 2012;Reidy et al, 2014), and location of care site (urban/rural) (Anaya et al, 2004;Balcha & Jeppsson, 2010;Boyer et al, 2010;Ekouevi et al, 2012).…”

Section: Structural Factorsmentioning

confidence: 99%

“…Other studies measured time to viral suppression. Mortality was assessed after a specific follow-up time (Balcha & Jeppsson, 2010;McGuire et al, 2012) or during the entire study period.…”

Section: Structural Factorsmentioning

confidence: 99%

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Structure and quality of outpatient care for people living with an HIV infection

et al. 2016

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Policy-makers and clinicians are faced with a gap of evidence to guide policy on standards for HIV outpatient care. Ongoing debates include which settings of care improve health outcomes, and how many HIV-infected patients a health-care provider should treat to gain and maintain expertise. In this article, we evaluate the studies that link health-care facility and care provider characteristics (i.e., structural factors) to health outcomes in HIV-infected patients. We searched the electronic databases MEDLINE, PUBMED, and EMBASE from inception until 1 January 2015. We included a total of 28 observational studies that were conducted after the introduction of combination antiretroviral therapy in 1996. Three aspects of the available research linking the structure to quality of HIV outpatient care were evaluated: (1) assessed structural characteristics (i.e., health-care facility and care provider characteristics); (2) measures of quality of HIV outpatient care; and (3) reported associations between structural characteristics and quality of care. Rather than scarcity of data, it is the diversity in methodology in the identified studies and the inconsistency of their results that led us to the conclusion that the scientific evidence is too weak to guide policy in HIV outpatient care. We provide recommendations on how to address this heterogeneity in future studies and offer specific suggestions for further reading that could be of interest for clinicians and researchers.ARTICLE HISTORY

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Decentralising HIV treatment in lower- and middle-income countries

Kredo

Ford

Adeniyi

et al. 2013

Cochrane Database of Systematic Reviews

122

115

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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

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Treatment Initiation, Program Attrition and Patient Treatment Outcomes Associated with Scale-Up and Decentralization of HIV Care in Rural Malawi

Cited by 32 publications

References 35 publications

Improving antiretroviral therapy scale-up and effectiveness through service integration and decentralization

Improving antiretroviral therapy scale-up and effectiveness through service integration and decentralization

Structure and quality of outpatient care for people living with an HIV infection

Decentralising HIV treatment in lower- and middle-income countries

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