Monday, February 8, 2016

Decentralizing Access to Antiretroviral Therapy for Children Living with HIV in Swaziland

BACKGROUND:
In 2007, Swaziland initiated a hub-and-spoke model for decentralizing antiretroviral therapy (ART) access for HIV-infected children (<15 years old). Decentralization was facilitated through: (1) down-referral of stable children on ART from overburdened central facilities (hubs) to primary healthcare clinics (spokes), and (2) pediatric ART initiation at spokes (spoke-initiation).

METHODS:
We conducted a nationally representative retrospective cohort study among children starting ART during 2004-2010 to assess effect of down-referral and spoke-initiation on rates of loss to follow-up (LTFU), death, and attrition (death or LTFU). Twelve of 28 pediatric ART hubs were randomly selected using probability-proportional-to-size sampling. Seven selected facilities had initiated hub-and-spoke decentralization by study start; at these facilities, 901 of 1,893 hub-initiated and maintained (hub-maintained) children, and 495 of 1,105 down-referred or spoke-initiated children were randomly selected for record abstraction. At the five hub-only facilities, 612 of 1,987 children were randomly selected. Multivariable proportional hazards regression was used to estimate adjusted hazards ratios (AHR) for effect of down-referral (a time-varying covariate) and spoke-initiation on outcomes.

RESULTS:
Among 2,008 children at ART initiation, median age was 5.0 years, median CD4 percentage 12.0%, median CD4 count 358 cells/┬ÁL, and median weight-for-age z-score -1.91. Controlling for known confounders, down-referral was strongly protective against LTFU (AHR 0.40; 95% CI, 0.20-0.79) and attrition (AHR 0.46; 95% CI, 0.26-0.83) but not mortality. Compared with hub-only children or hub-maintained children, spoke-initiated children had similar outcomes.

CONCLUSIONS:
Decentralization of pediatric ART through down-referral and spoke-initiation within a hub-and-spoke system should be continued and might improve program outcomes.

Purchase full article at:   http://goo.gl/Eax9ej

  • Division of Global HIV/AIDS, Centers for Disease Control and Prevention, Atlanta, U.S.A 
  • 2 ICAP, Columbia University, Mailman School of Public Health, New York, U.S.A 
  • 3 Ministry of Health, Government of the Kingdom of Swaziland, Mbabane, Swaziland 
  • 4 Division of Global HIV/AIDS, Centers for Disease Control and Prevention, Mbabane, Swaziland. 
  •  2016 Feb 4




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