title: Scaling-up access to antiretroviral therapy for children: a cohort study evaluating care and treatment at mobile and hospital-affiliated HIV clinics in rural Zambia.
abstract: BACKGROUND
  Travel time and distance are barriers to care for HIV-infected children in rural sub-Saharan Africa. Decentralization of care is one strategy to scale-up access to antiretroviral therapy (ART), but few programs have been evaluated. We compared outcomes for children receiving care in mobile and hospital-affiliated HIV clinics in rural Zambia.
  
  
  METHODS
  Outcomes were measured within an ongoing cohort study of HIV-infected children seeking care at Macha Hospital, Zambia from 2007 to 2012. Children in the outreach clinic group received care from the Macha HIV clinic and transferred to one of three outreach clinics. Children in the hospital-affiliated clinic group received care at Macha HIV clinic and reported Macha Hospital as the nearest healthcare facility.
  
  
  RESULTS
  Seventy-seven children transferred to the outreach clinics and were included in the analysis. Travel time to the outreach clinics was significantly shorter and fewer caretakers used public transportation, resulting in lower transportation costs and fewer obstacles accessing the clinic. Some caretakers and health care providers reported inferior quality of service provision at the outreach clinics. Sixty-eight children received ART at the outreach clinics and were compared to 41 children in the hospital-affiliated clinic group. At ART initiation, median age, weight-for-age z-scores (WAZ) and CD4(+) T-cell percentages were similar for children in the hospital-affiliated and outreach clinic groups. Children in both groups experienced similar increases in WAZ and CD4(+) T-cell percentages.
  
  
  CONCLUSIONS
  HIV care and treatment can be effectively delivered to HIV-infected children at rural health centers through mobile ART teams, removing potential barriers to uptake and retention. Outreach teams should be supported to increase access to HIV care and treatment in rural areas.
authors.affiliation: Macha Research Trust, Macha Hospital, Choma, Zambia; Department of Immunology and Infectious Diseases, Erasmus University Rotterdam, the Netherlands.
authors.forename: Janneke H
authors.initials: JH
authors.lastname: van Dijk
authors.affiliation: Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America.
authors.forename: William J
authors.initials: WJ
authors.lastname: Moss
authors.affiliation: Macha Research Trust, Macha Hospital, Choma, Zambia.
authors.forename: Francis
authors.initials: F
authors.lastname: Hamangaba
authors.affiliation: Macha Research Trust, Macha Hospital, Choma, Zambia.
authors.forename: Bornface
authors.initials: B
authors.lastname: Munsanje
authors.affiliation: Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America.
authors.forename: Catherine G
authors.initials: CG
authors.lastname: Sutcliffe
mesh_terms: D019380:Anti-HIV Agents / Q000600:supply & distribution / Q000627:therapeutic use*; D002648:Child; D002675:Child, Preschool; D015331:Cohort Studies; D005260:Female; D015658:HIV Infections / Q000188:drug therapy*; D006297:Health Services Accessibility; D006801:Humans; D008297:Male; D008952:Mobile Health Units / Q000458:organization & administration*; D010044:Outpatient Clinics, Hospital / Q000458:organization & administration*; D015024:Zambia
chemical_list: D019380:Anti-HIV Agents