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.
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.
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regardless of language or publication status (published, unpublished, in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'.
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.
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
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
Kredo, T.; Ford, N.; Adeniyi, F.B.; Garner, P. Decentralising HIV treatment in lower- and middle-income countries. Cochrane Database of Systematic Reviews (2013) (Issue 6) Art. No.: CD009987. [DOI: 10.1002/14651858.CD009987.pub2]
Decentralising HIV treatment in lower- and middle-income countries