Decentralising HIV treatment in lower- and middle-income countries

Folasade B. Adeniyi; Nathan Ford; Paul Garner; Tamara Kredo

摘要

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.METHODS: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a comprehensive search to identify all relevant studies regardless of language or publication status (published, unpublished, in press, and in progress) from 1 January 1996 to 31 March 2013, and contacted relevant organisations and researchers.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.

机译：背景：决策者，卫生人员和社区认识到，中低收入国家的卫生服务需要改善人们获得艾滋病毒治疗的机会并保留其治疗方案。一种策略是将抗逆转录病毒药物从医院转移到更多的外围医疗机构，甚至超越医疗机构。这可以增加获得护理的人数，改善健康状况，并增加对治疗计划的保留。另一方面，在卫生服务水平较低或社区水平上提供护理可能会降低护理质量并导致更差的健康结果。为了解决这些不确定性，我们总结了研究研究，以分散抗逆转录病毒疗法的服务交付的风险和收益。目的：评估在健康系统中将HIV分散治疗和护理至更基本水平的各种模型对启动和维持抗逆转录病毒疗法的影响方法：检索方法：我们进行了全面的检索，从1996年1月1日至2013年3月31日，不考虑语言或出版物的状态（出版的，未出版的，正在出版的和进行中的）来识别所有相关研究，并与相关组织和研究人员进行了联系。。搜索词包括“权力下放”，“下属转诊”，“医疗保健提供”和“医疗服务可及性”。选择标准：我们的纳入标准是对照试验（随机和非随机），研究前后的对照，以及队列（前瞻性和回顾性），在这些人群中，HIV感染者开始采用抗逆转录病毒疗法或维持分散治疗在中低收入国家/地区的设置。我们将权力下放定义为在卫生系统中向比较者提供更基本的治疗。数据收集和分析：两位作者应用了纳入标准并独立提取了数据。我们设计了一个框架来描述不同的权力下放策略，然后针对这些策略进行分组研究。使用随机效应荟萃分析汇总数据。因为已知在HIV计划中失去后续行动会导致一些死亡，所以我们将损耗作为主要结局，定义为死亡加上后续行动的损失。主要结果：16项研究符合纳入标准，除1项来自非洲外，其余2项随机研究和14项队列研究。抗逆转录病毒疗法始于医院，并维持在医疗中心（部分分权）可能会减少损耗（RR 0.46，95％CI 0.29至0.71，4个研究，39 090例患者，质量中等）。使用该模型可能失去护理的患者更少（RR 0.55，95％CI 0.45至0.69，低质量证据）。我们不确定在卫生中心开始和维持的抗逆转录病毒治疗的减员率是否存在差异（完全分权）与12个月的医院相比是否存在差异（RR 0.70，95％CI 0.47至1.02;四项研究，共56360名患者，非常低质量证据），但使用该模型失去护理的患者可能更少（RR 0.3，95％CI 0.17至0.54，中等质量证据）。当训练有素的志愿者在家中进行抗逆转录病毒维持疗法时，在12个月时的流失率可能没有差异（RR 0.95,95％CI 0.62至1.46，两项试验，1453例患者，中等质量的证据）。 HIV护理旨在改善患者的获得和保持护理的水平。大多数数据来自高质量的队列研究，但不能排除治疗部位与预后之间的混淆。然而，这项审查发现，在部分分散治疗模式中，在医院开始使用抗逆转录病毒药物并在医疗中心继续使用的情况下，磨损率似乎较低。在健康中心开始使用抗逆转录病毒药物并继续使用抗逆转录病毒药物后，未发现流失的差异，但失去护理的患者较少。对于训练有素的志愿者在家中提供的抗逆转录病毒疗法，与基于设施的护理相比，结果没有差异。

Decentralising HIV treatment in lower- and middle-income countries

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