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/µL, 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.
By: Auld AF1, Nuwagaba-Biribonwoha H, Azih C, Kamiru H, Baughman AL, Agolory S, Abrams E, Ellerbrock TV, Okello V, Bicego G, Ehrenkranz P.
- 1 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.
- Pediatr Infect Dis J. 2016 Feb 4
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