title: Outcomes of stable HIV-positive patients down-referred from a doctor-managed antiretroviral therapy clinic to a nurse-managed primary health clinic for monitoring and treatment.
abstract: OBJECTIVE
  To compare clinical, immunologic and virologic outcomes among stable HIV-positive patients down-referred to a nurse-managed primary healthcare clinic (PHC) for treatment maintenance to those who remained at a doctor-managed treatment-initiation site.
  
  
  METHODS
  We conducted a matched cohort analysis among stable HIV patients at the Themba Lethu Clinic in Johannesburg, South Africa. Eligible patients met the criteria for down-referral [undetectable viral load <10 months, antiretroviral therapy (ART) >11 months, CD4 cell count ≥200 cells/μl, stable weight and no opportunistic infections], regardless of whether they were down-referred to a PHC for treatment maintenance between February 2008 and January 2009. Patients were matched 1 : 3 (down-referred : treatment-initiation) using propensity scores.
  
  
  METHODS
  We calculated rates and hazard ratios (HRs) for the effect of down-referral on loss to follow-up (LTFU) and mortality and the relative risk of down-referral on viral rebound by 12 months of follow-up.
  
  
  RESULTS
  Six hundred and ninety-three down-referred patients were matched to 2079 treatment-initiation patients. Two (0.3%) down-referred and 32 (1.5%) treatment-initiation patients died, 10 (1.4%) down-referred and 87 (4.2%) treatment-initiation patients were lost, and 22 (3.3%) down-referred and 100 (5.6%) treatment-initiation patients experienced viral rebound by 12 months of follow-up. After adjustment, patients down-referred were less likely to die [hazard ratio (HR) 0.2, 95% confidence interval (CI) 0.04-0.8], become LTFU (HR 0.3, 95% CI 0.2-0.6) or experience viral rebound (relative risk 0.6, 95% CI 0.4-0.9) than treatment-initiation patients during follow-up.
  
  
  CONCLUSIONS
  The utilization of nurse-managed PHCs for treatment maintenance of stable patients could decrease the burden on specialized doctor-managed ART clinics. Patient outcomes for down-referred patients at PHCs appear equal, if not better, than those achieved at ART clinics among stable patients.
authors: Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa. abrennan@bu.edu
authors: Alana T
authors: AT
authors: Brennan
authors: Lawrence
authors: L
authors: Long
authors: Mhairi
authors: M
authors: Maskew
authors: Ian
authors: I
authors: Sanne
authors: Imogen
authors: I
authors: Jaffray
authors: Patrick
authors: P
authors: MacPhail
authors: Matthew P
authors: MP
authors: Fox
mesh_terms: D000328:Adult; D019380:Anti-HIV Agents / Q000627:therapeutic use*; D018791:CD4 Lymphocyte Count; D015331:Cohort Studies; D005260:Female; D015658:HIV Infections / Q000188:drug therapy* / Q000276:immunology / Q000821:virology; D015497:HIV-1; D006801:Humans; D008297:Male; D009718:Nurse Administrators; D011320:Primary Health Care; D016016:Proportional Hazards Models; D012017:Referral and Consultation; D013019:South Africa / Q000453:epidemiology; D016896:Treatment Outcome; D019562:Viral Load; D000078329:Workforce
chemical_list: D019380:Anti-HIV Agents