Decentralised paediatric HIV care in Ethiopia: a comparison between outcomes of patients managed in health centres and in a hospital clinic.
BACKGROUND
In order to increase access to antiretroviral therapy (ART) in HIV-infected children, paediatric HIV care has been introduced in health centres in Ethiopia, where patients are managed by health professionals with limited training.


OBJECTIVE
To compare outcomes of paediatric HIV care in hospital and health centre clinics and to determine risk factors for death and loss to follow-up (LTFU).


METHODS
Retrospective comparison of patient characteristics and outcomes among children managed in a public hospital and all five public health centres in the uptake area.


RESULTS
Among 1,960 patients (health centres 572, hospital clinic 1,388), 34% were lost to follow-up, 2% died, 14% were transferred out, and 46% remained in care. Children initiating ART in the hospital clinic had lower median CD4 cell counts (age <1 year: 575 vs. 1,183 cells/mm³, p=0.024; age 1-5 years: 370 vs. 598 cells/mm³, p<0.001; age >5 years: 186 vs. 259 cells/mm³, p<0.001), and a higher proportion were <1 year of age (22% vs. 15%, p=0.025). ART initiation rates and retention in care were similar between children managed in health centres and in the hospital clinic (36% vs. 37% and 47% vs. 46%, respectively). Among patients starting ART, mortality was associated with age <1 year [hazard ratio (HR) 12.0; 95% confidence interval (CI): 3.5, 41]. LTFU was associated with CD4 cell counts <350 cells/mm³ (HR 1.8; 95% CI: 1.2, 3.0), weight-for-age z-scores below -4 (HR 2.8; 95% CI: 1.4, 5.6), and age <5 years (1-5 years: HR 1.6; 95% CI: 1.0, 2.5; <1 year: HR 3.3; 95% CI: 1.6, 6.6).


CONCLUSIONS
Outcomes of HIV care were similar for Ethiopian children managed in a hospital clinic or in health centres. However, patients treated at the hospital clinic had characteristics of more advanced disease. Rates of LTFU were high in both types of health facility.
Infectious Disease Research Unit, Department of Clinical Sciences, Malmö, Lund University, Malmö, Sweden.
Oskar
O
Hagströmer
Lars
L
Lundstedt
Taye Tolera
TT
Balcha
Per
P
Björkman
D000293:Adolescent; D018791:CD4 Lymphocyte Count; D002648:Child; D002662:Child Health Services; D002675:Child, Preschool; D005002:Ethiopia; D005260:Female; D015658:HIV Infections / Q000401:mortality / Q000628:therapy*; D006801:Humans; D007223:Infant; D059012:Lost to Follow-Up; D008297:Male; D010044:Outpatient Clinics, Hospital; D063868:Patient Outcome Assessment; D011787:Quality of Health Care; D012307:Risk Factors
ART; Ethiopia; HIV; decentralisation; paediatric; primary health care