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.

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a comprehensive search to identify all relevant studies regardless of language or publication status (published, unpublished, in press, and in progress) from 1 January 1996 to 31 March 2013, and contacted relevant organisations and researchers.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 meta-analysis. 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 decentralisation) compared to a hospital at 12 months (RR 0.70, 95% CI 0.47 to 1.02; four studies, 56 360 patients, very low quality evidence), but there are probably fewer patients lost to care with this model (RR 0.3, 95% CI 0.17 to 0.54, moderate quality evidence).When antiretroviral maintenance therapy is delivered at home by trained volunteers, there is probably no difference in attrition at 12 months (RR 0.95, 95% CI 0.62 to 1.46, two trials, 1453 patients, moderate quality evidence).

Authors' conclusions: Decentralisation of HIV care aims to improve patient access and retention in care. Most data were from good quality cohort studies but confounding between site of treatment and outcomes cannot be excluded. Nevertheless, this review found that attrition appears to be lower in partial decentralisation models of treatment, where antiretrovirals were started at hospital and continued in the health centre; with antiretroviral drugs started and continued at health centres, no difference in attrition was detected, but there were fewer patients lost to care. For antiretroviral therapy provided at home by trained volunteers, no difference in outcomes were detected when compared to facility-based care.

Conflict of interest statement

None declared.

Figures

1

Study flow diagram.

2

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

3

Forest plot of comparison: 1 Partial decentralisation ‐ initiation in hospital, maintenance at health centre, outcome: 1.1 Death or lost to care (12 months).

4

Forest plot of comparison: 1 Partial decentralisation ‐ initiation in hospital, maintenance at health centre, outcome: 1.2 Lost to care.

5

Forest plot of comparison: 1 Partial decentralisation ‐ initiation in hospital, maintenance at health centre, outcome: 1.3 Death.

6

Forest plot of comparison: 2 Full decentralisation ‐ initiation and maintenance in health centre, outcome: 2.1 Death or lost to care (12 months).

7

Forest plot of comparison: 2 Full decentralisation ‐ initiation and maintenance in health centre, outcome: 2.2 Lost to care.

8

Forest plot of comparison: 2 Full decentralisation ‐ initiation and maintenance in health centre, outcome: 2.3 Death.

9

Forest plot of comparison: 3 Decentralisation ‐ from the facility to the community for antiretroviral maintenance therapy, outcome: 3.1 Death or lost to care (12 months).

10

Forest plot of comparison: 3 Decentralisation ‐ to community from facility, outcome: 3.2 lost to care.

11

Forest plot of comparison: 3 Decentralisation ‐ to community from facility, outcome: 3.1 Death.

1.1. Analysis

Comparison 1 Partial decentralisation ‐ initiation in hospital, maintenance at health centre, Outcome 1 Death or lost to care (12 months).

1.2. Analysis

Comparison 1 Partial decentralisation ‐ initiation in hospital, maintenance at health centre, Outcome 2 Lost to care.

1.3. Analysis

Comparison 1 Partial decentralisation ‐ initiation in hospital, maintenance at health centre, Outcome 3 Death.

2.1. Analysis

Comparison 2 Full decentralisation ‐ initiation and maintenance in health centre, Outcome 1 Death or lost to care (12 months).

2.2. Analysis

Comparison 2 Full decentralisation ‐ initiation and maintenance in health centre, Outcome 2 Lost to care.

2.3. Analysis

Comparison 2 Full decentralisation ‐ initiation and maintenance in health centre, Outcome 3 Death.

3.1. Analysis

Comparison 3 Decentralisation ‐ from the facility to the community for antiretroviral maintenance therapy, Outcome 1 Death or lost to care (12 months).

3.2. Analysis

Comparison 3 Decentralisation ‐ from the facility to the community for antiretroviral maintenance therapy, Outcome 2 Lost to care.

3.3. Analysis

Comparison 3 Decentralisation ‐ from the facility to the community for antiretroviral maintenance therapy, Outcome 3 Death.

References

References to studies included in this review Assefa 2012 {published data only}

Balcha 2010 {published data only} Bedelu 2007 {published data only} Bock 2008 {published data only} Brennan 2011 {published data only} Chan 2010 {published data only} Fatti 2010 {published data only} Fayorsey 2013 {published data only} Hansudewechakul 2012 {published data only} Humphreys 2010 {published data only} Jaffar 2009 {published data only} Kipp 2010 {published data only} Massaquoi 2009 {published data only} McGuire 2012 {published data only} Odafe 2012 {published data only} Selke 2010 {published data only} References to studies excluded from this review Babigumira 2009 {published data only} Bemelmans 2010 {published data only} Bolton‐Moore 2007 {published data only} Boyer 2010 {published data only} Boyer 2012 {published data only} Chu 2010 {published data only} Cohen 2009 {published data only} Ingle 2010 {published data only} Lambdin 2013 {published data only} Leon 2011 {published data only} Shumbusho 2009 {published data only} Stein 2007 {published data only} Tene 2013 {published data only} References to studies awaiting assessment Assefa 2012b {published data only} Labhart 2012 {unpublished data only} Miyano 2012 {published data only} Morsheimer (unpublished) {unpublished data only} Van Dijk 2012 {published data only} References to ongoing studies NCT 01414413 {published data only} Additional references Brinkhof 2009 Decroo 2009 Deeks 2008 Ford 2011 Fox 2010 GRADEpro 2008 [Computer program] Guyatt 2011 Higgins 2008 Higgins 2008a Kagee 2011 Kredo 2012 Miller 2010 Newcastle‐Ottawa Scale Review Manager 2011 [Computer program] UNAIDS 2011 Ware 2009 WHO 2008