Successful clinical outcomes following decentralization of tertiary paediatric HIV care to a community-based paediatric antiretroviral treatment network, Chiangrai, Thailand, 2002 to 2008.
BACKGROUND
Most paediatric antiretroviral treatments (ARTs) in Thailand are limited to tertiary care hospitals. To decentralize paediatric HIV treatment and care, Chiangrai Prachanukroh Hospital (CRH) strengthened a provincial paediatric HIV care network by training community hospital (CH) care teams to receive referrals of children for community follow-up. In this study, we assessed factors associated with death and clinical outcomes of HIV-infected children who received care at CRH and CHs after implementation of a community-based paediatric HIV care network.


METHODS
Clinical records were abstracted for all children who initiated ART at CRH. Paired Wilcoxon signed rank tests were used to assess CD4% and virological change among all children. Cox proportional hazard models were used to assess factors associated with death. Treatment outcomes (CD4%, viral load (VL) and weight-for-age Z-score (WAZ)) were compared between CRH and CH children who met the criteria for analysis.


RESULTS
Between February 2002 and April 2008, 423 HIV-infected children initiated ART and 410 included in the cohort analysis. Median follow-up for the cohort was 28 months (interquartile range (IQR)=12 to 42); 169 (41%) children were referred for follow-up at CH. As of 31 March 2008, 42 (10%) children had died. Baseline WAZ (< -2 (p=0.001)) and baseline CD4% (<5% (p=0.015)) were independently associated with death. At 48 months, 86% of ART-naïve children in follow-up had VL<400 copies/ml. For sub-group analysis, 133 children at CRH and 154 at CHs were included for comparison. Median baseline WAZ was lower in CH children than in CRH children (p=0.001); in both groups, WAZ, CD4% and VL improved after ART with no difference in rate of WAZ and CD4% gain (p=0.421 and 0.207, respectively).


CONCLUSIONS
Children at CHs had more severe immunological suppression and low WAZ at baseline. Community- and tertiary care-based paediatric ART follow-ups result in equally beneficial outcomes with the strengthening of a provincial referral network between tertiary and community care. Nutrition interventions may benefit children in community-based HIV treatment and care.
Chiangrai Prachanukroh Hospital, Ministry of Public Health, Chiangrai, Thailand.
Rawiwan
R
Hansudewechakul
Thananda
T
Naiwatanakul
Abraham
A
Katana
Worawan
W
Faikratok
Rangsima
R
Lolekha
Vorapathu
V
Thainuea
Michelle S
MS
McConnell
D000293:Adolescent; D044966:Anti-Retroviral Agents / Q000008:administration & dosage*; D002648:Child; D002675:Child, Preschool; D003695:Delivery of Health Care / Q000458:organization & administration*; D005260:Female; D015658:HIV Infections / Q000175:diagnosis* / Q000188:drug therapy*; D006302:Health Services Research; D006801:Humans; D008297:Male; D011057:Politics; D013785:Thailand; D016896:Treatment Outcome
D044966:Anti-Retroviral Agents