Outcome assessment of decentralization of antiretroviral therapy provision in a rural district of Malawi using an integrated primary care model.
OBJECTIVE
To assess the effect of decentralization (DC) of antiretroviral therapy (ART) provision in a rural district of Malawi using an integrated primary care model.


METHODS
Between October 2004 and December 2008, 8093 patients (63% women) were registered for ART. Of these, 3440 (43%) were decentralized to health centres for follow-up ART care. We applied multivariate regression analysis that adjusted for sex, age, clinical stage at initiation, type of regimen, presence of side effects because of ART, and duration of treatment and follow-up at site of analysis.


RESULTS
Patients managed at health centres had lower mortality [adjusted OR 0.19 (95% C.I. 0.15-0.25)] and lower loss to follow-up (defaulted from treatment) [adjusted OR 0.48 (95% C.I. 0.40-0.58)]. During the first 10 months of follow-up, those decentralized to health centres were approximately 60% less likely to default than those not decentralized; and after 10 months of follow-up, 40% less likely to default. DC was significantly associated with a reduced risk of death from 0 to 25 months of follow-up. The lower mortality may be explained by the selection of stable patients for DC, and the mentorship and supportive supervision of lower cadre health workers to identify and refer complicated cases.


CONCLUSIONS
Decentralization of follow-up ART care to rural health facilities, using an integrated primary care model, appears a safe and effective way to rapidly scale-up ART and improves both geographical equity in access to HIV-related services and adherence to ART.
Chan
Adrienne K
AK
Dignitas International, Zomba, Malawi.
Mateyu
Gabriel
G
Jahn
Andreas
A
Schouten
Erik
E
Arora
Paul
P
Mlotha
William
W
Kambanji
Marion
M
van Lettow
Monique
M
D000293:Adolescent; D000328:Adult; D019380:Anti-HIV Agents / Q000008:administration & dosage; D023241:Antiretroviral Therapy, Highly Active; D002648:Child; D002675:Child, Preschool; D003695:Delivery of Health Care / Q000458:organization & administration*; D004334:Drug Administration Schedule; D004812:Epidemiologic Methods; D005260:Female; D015658:HIV Infections / Q000188:drug therapy* / Q000401:mortality; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008134:Long-Term Care / Q000458:organization & administration; D008295:Malawi / Q000453:epidemiology; D008297:Male; D017146:Models, Organizational; D017063:Outcome Assessment, Health Care; D011320:Primary Health Care / Q000458:organization & administration; D019035:Rural Health Services / Q000458:organization & administration*; D055815:Young Adult; D016903:Drug Monitoring
D019380:Anti-HIV Agents