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

Abstract

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.

Enhancing Linkage and Retention in HIV Care: a Review of Interventions for Highly Resourced and Resource-Poor Settings

“…Some studies have shown that patient behaviors in response to well-intentioned interventions may be far different then anticipated, due to factors overlooked by investigators or policy makers. For example, a prospective cohort study of 754 HIV-infected patients in Tanzania showed that despite rapid decentralization of care centers, 98% of patients never changed their primary treatment center and 75% continued to receive care at established tertiary care centers after 3.5 years of follow-up [80]. Although the authors posited stigma of receiving HIV care close to home and patient mistrust of the quality of care at newer treatment centers as possible reasons for their observations, the only way to ascertain the rationale for such behavioral patterns is direct patient input.…”

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

“…A study conducted in Tanzania found that some patients preferred to attend more established health facilities rather than seeking care at the closest HIV care facilities. 21 A study on patient attitudes towards decentralisation at an urban clinic in South Africa, showed some patients had reservations about receiving ART close to where they live due to concerns about stigma, lack of confidentiality, untrained staff and poor relations with nurses. 22 However, in this study, fear of drug stock-outs was given by around half of the HIV-positive individuals as the reason for not transferring to the primary care facility for follow-up.…”

Feasibility of an HIV self-testing intervention: a formative qualitative study among individuals, community leaders, and HIV testing experts in northern Tanzania

“…Of these health facilities, 17 were public, 3 private for-profits, 3 faith-based organizations, and 2 Non-governmental organizations. Besides, eight HIV Care and Treatment Centers (CTCs) provided access to confirmatory tests and antiretroviral therapy for clients who tested HIV positive [40]. Other HTS included HIV testing campaigns and mobile outreach testing available at venues such as schools, markets, workplaces, etc.…”