title: Health service delivery models for the provision of antiretroviral therapy in sub-Saharan Africa: a systematic review.
abstract: OBJECTIVE
  In response to the lack of evidence-based guidance for how to continue scaling up antiretroviral therapy (ART) in ways that make optimal use of limited resources, to assess comparative studies of ART service delivery models implemented in sub-Saharan Africa.
  
  
  METHODS
  A systematic literature search and analysis of studies that compared two or more methods of ART service delivery using either CD4 count or viral load as a primary outcome.
  
  
  RESULTS
  Most studies identified in this review were small and non-randomised, with low statistical power. Four of the 30 articles identified by this review conclude that nurse management of ART compares favourably to physician management. Seven provide evidence of the viability of managing ART at lower levels within the health system, and one indicates that vertical and integrated ART programmes can achieve similar outcomes. Five articles show that community/home-based ART management can be as effective as facility-based ART management. Five of seven articles investigating community support link it to better clinical outcomes. The results of four studies suggest that directly observed therapy may not be an important component of ART programmes.
  
  
  CONCLUSIONS
  Given that the scale-up of antiretroviral therapy represents the most sweeping change in healthcare delivery in sub-Saharan Africa in recent years, it is surprising to not find more evidence from comparative studies to inform implementation strategies. The studies reported on a wide range of service delivery models, making it difficult to draw conclusions about some models. The strongest evidence was related to the feasibility of decentralisation and task-shifting, both of which appear to be effective strategies.
authors: CHIP, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.
authors: Jeffrey V
authors: JV
authors: Lazarus
authors: Kelly
authors: K
authors: Safreed-Harmon
authors: Joey
authors: J
authors: Nicholson
authors: Shabbar
authors: S
authors: Jaffar
mesh_terms: D017954:Africa South of the Sahara; D019380:Anti-HIV Agents / Q000627:therapeutic use*; D003695:Delivery of Health Care / Q000379:methods*; D015658:HIV Infections / Q000188:drug therapy*; D006295:Health Resources; D006296:Health Services; D006801:Humans; D008962:Models, Theoretical; D012111:Residence Characteristics
chemical_list: D019380:Anti-HIV Agents
keywords: ART; Afrique subsaharienne; TAR; antiretroviral therapy; health systems; prestation de service; service delivery; servicios de entrega; sistemas de salud; sub-Saharan Africa; systèmes de santé; África subsahariana