Treatment initiation, program attrition and patient treatment outcomes associated with scale-up and decentralization of HIV care in rural Malawi.
OBJECTIVE
To describe patient antiretroviral therapy (cART) outcomes associated with intensive decentralization of services in a rural HIV program in Malawi.


METHODS
Longitudinal analysis of data from HIV-infected patients starting cART between August 2001 and December 2008 and of a cross-sectional immunovirological assessment conducted 12 (±2) months after therapy start. One-year mortality, lost to follow-up, and attrition (deaths and lost to follow-up) rates were estimated with exact Poisson 95% confidence intervals (CI) by type of care delivery and year of initiation. Association of virological suppression (<50 copies/mL) and immunological success (CD4 gain ≥100 cells/µL), with type of care was investigated using multiple logistic regression.


RESULTS
During the study period, 4322 cART patients received centralized care and 11,090 decentralized care. At therapy start, patients treated in decentralized health facilities had higher median CD4 count levels (167 vs. 130 cell/µL, P<0.0001) than other patients. Two years after cART start, program attrition was lower in decentralized than centralized facilities (9.9 per 100 person-years, 95% CI: 9.5-10.4 vs. 20.8 per 100 person-years, 95% CI: 19.7-22.0). One year after treatment start, differences in immunological success (adjusted OR=1.23, 95% CI: 0.83-1.83), and viral suppression (adjusted OR=0.80, 95% CI: 0.56-1.14) between patients followed at centralized and decentralized facilities were not statistically significant.


CONCLUSIONS
In rural Malawi, 1- and 2-year program attrition was lower in decentralized than in centralized health facilities and no statistically significant differences in one-year immunovirological outcomes were observed between the two health care levels. Longer follow-up is needed to confirm these results.
Epicentre, Clinical Research Department, Nairobi, Kenya.
Megan
M
McGuire
Loretxu
L
Pinoges
Rupa
R
Kanapathipillai
Tamika
T
Munyenyembe
Martha
M
Huckabee
Simon
S
Makombe
Elisabeth
E
Szumilin
Annette
A
Heinzelmann
Mar
M
Pujades-Rodríguez
D000328:Adult; D019380:Anti-HIV Agents / Q000627:therapeutic use*; D018791:CD4 Lymphocyte Count; D005260:Female; D015658:HIV Infections / Q000188:drug therapy* / Q000401:mortality; D006801:Humans; D008137:Longitudinal Studies; D008295:Malawi / Q000453:epidemiology; D008297:Male; D008875:Middle Aged; D010352:Patient Dropouts; D012189:Retrospective Studies; D012307:Risk Factors; D019035:Rural Health Services / Q000458:organization & administration*; D012424:Rural Population; D016896:Treatment Outcome
D019380:Anti-HIV Agents