title: Outcomes of antiretroviral treatment programmes in rural Lesotho: health centres and hospitals compared.
abstract: BACKGROUND
  Lesotho was among the first countries to adopt decentralization of care from hospitals to nurse-led health centres (HCs) to scale up the provision of antiretroviral therapy (ART). We compared outcomes between patients who started ART at HCs and hospitals in two rural catchment areas in Lesotho.
  
  
  METHODS
  The two catchment areas comprise two hospitals and 12 HCs. Patients ≥16 years starting ART at a hospital or HC between 2008 and 2011 were included. Loss to follow-up (LTFU) was defined as not returning to the facility for ≥180 days after the last visit, no follow-up (no FUP) as not returning after starting ART, and retention in care as alive and on ART at the facility. The data were analysed using logistic regression, competing risk regression and Kaplan-Meier methods. Multivariable analyses were adjusted for sex, age, CD4 cell count, World Health Organization stage, catchment area and type of ART. All analyses were stratified by gender.
  
  
  RESULTS
  Of 3747 patients, 2042 (54.5%) started ART at HCs. Both women and men at hospitals had more advanced clinical and immunological stages of disease than those at HCs. Over 5445 patient-years, 420 died and 475 were LTFU. Kaplan-Meier estimates for three-year retention were 68.7 and 69.7% at HCs and hospitals, respectively, among women (p=0.81) and 68.8% at HCs versus 54.7% at hospitals among men (p<0.001). These findings persisted in adjusted analyses, with similar retention at HCs and hospitals among women (odds ratio (OR): 0.89, 95% confidence interval (CI): 0.73-1.09) and higher retention at HCs among men (OR: 1.53, 95% CI: 1.20-1.96). The latter result was mainly driven by a lower proportion of patients LTFU at HCs (OR: 0.68, 95% CI: 0.51-0.93).
  
  
  CONCLUSIONS
  In rural Lesotho, overall retention in care did not differ significantly between nurse-led HCs and hospitals. However, men seemed to benefit most from starting ART at HCs, as they were more likely to remain in care in these facilities compared to hospitals.
authors.affiliation: SolidarMed Lesotho, Maseru, Lesotho; University Medical Clinic, Kantonsspital Baselland, Liestal, Switzerland; niklaus.labhardt@gmail.com.
authors.forename: Niklaus Daniel
authors.initials: ND
authors.lastname: Labhardt
authors.forename: Olivia
authors.initials: O
authors.lastname: Keiser
authors.forename: Motlalepula
authors.initials: M
authors.lastname: Sello
authors.forename: Thabo Ishmael
authors.initials: TI
authors.lastname: Lejone
authors.forename: Karolin
authors.initials: K
authors.lastname: Pfeiffer
authors.forename: Mary-Ann
authors.initials: MA
authors.lastname: Davies
authors.forename: Matthias
authors.initials: M
authors.lastname: Egger
authors.forename: Jochen
authors.initials: J
authors.lastname: Ehmer
authors.forename: Gilles
authors.initials: G
authors.lastname: Wandeler
mesh_terms: D000328:Adult; D044966:Anti-Retroviral Agents / Q000627:therapeutic use*; D003151:Community Health Centers; D005260:Female; D015658:HIV Infections / Q000188:drug therapy*; D006761:Hospitals; D006801:Humans; D007927:Lesotho; D008297:Male; D008875:Middle Aged; D012424:Rural Population; D016896:Treatment Outcome; D016903:Drug Monitoring
chemical_list: D044966:Anti-Retroviral Agents
keywords: HIV; antiretroviral treatment; decentralization; nurse-based care; retention in care; rural Southern Africa; task shifting