title: Decentralization of pediatric HIV care and treatment in five sub-Saharan African countries.
abstract: BACKGROUND
  In resource-limited settings, decentralization of HIV care and treatment is a cornerstone of universal care and rapid scale-up. We compared trends in pediatric enrollment and outcomes at primary (PHFs) vs secondary/tertiary health facilities (SHFs).
  
  
  METHODS
  Using aggregate program data reported quarterly from 274 public facilities in Kenya, Lesotho, Mozambique, Rwanda, and Tanzania from January 2008 to March 2010, we examined trends in number of children younger than 15 years of age initiating antiretroviral treatment (ART) by facility type. We compared clinic-level lost to follow-up (LTFU) and mortality per 100 person-years (PYs) on ART during the period by facility type.
  
  
  RESULTS
  During the 2-year period, 17,155 children enrolled in HIV care and 8475 initiated ART in 182 (66%) PHFs and 92(34%) SHFs. PHFs increased from 56 to 182, whereas SHFs increased from 72 to 92 sites. SHFs accounted for 71% of children initiating ART; however, the proportion of children initiating ART each quarter at PHFs increased from 17% (129) to 44% (463) in conjunction with an increase in PHFs during observation period. The average LTFU and mortality rates for children on ART were 9.8/100 PYs and 5.2/100 PYs, respectively, at PHFs and 20.2/100 PYs and 6.0/100 PYs, respectively, at SHFs. Adjusted models show PHFs associated with lower LTFU (adjusted rate ratio = 0.55; P = 0.022) and lower mortality (adjusted rate ratio = 0.66; P = 0.028).
  
  
  CONCLUSIONS
  The expansion of pediatric services to PHFs has resulted in increased numbers of children on ART. Early findings suggest lower rates of LTFU and mortality at PHFs. Successful scale-up will require further expansion of pediatric services within PHFs.
authors: Clinical and Training Unit, ICAP, Columbia University Mailman School of Public Health, New York, NY 10031, USA. rf2190@columbia.edu
authors: Ruby N
authors: RN
authors: Fayorsey
authors: Suzue
authors: S
authors: Saito
authors: Rosalind J
authors: RJ
authors: Carter
authors: Eduarda
authors: E
authors: Gusmao
authors: Koen
authors: K
authors: Frederix
authors: Emily
authors: E
authors: Koech-Keter
authors: Gilbert
authors: G
authors: Tene
authors: Milembe
authors: M
authors: Panya
authors: Elaine J
authors: EJ
authors: Abrams
mesh_terms: D000293:Adolescent; D017954:Africa South of the Sahara; D019380:Anti-HIV Agents / Q000627:therapeutic use*; D018791:CD4 Lymphocyte Count; D002648:Child; D002675:Child, Preschool; D006678:HIV; D015658:HIV Infections / Q000188:drug therapy* / Q000821:virology; D006268:Health Facilities / Q000639:trends*; D006801:Humans; D007223:Infant; D011057:Politics; D012044:Regression Analysis; D012189:Retrospective Studies
chemical_list: D019380:Anti-HIV Agents