Implementation and Operational Research: Evaluation of Swaziland's Hub-and-Spoke Model for Decentralizing Access to Antiretroviral Therapy Services.
BACKGROUND
In 2007, Swaziland initiated a hub-and-spoke model for decentralizing antiretroviral therapy (ART) access. Decentralization was facilitated through (1) down-referral of stable ART patients from overburdened central facilities (hubs) to primary health care clinics (spokes) and (2) ART initiation at spokes (spoke initiation).


METHODS
We conducted a nationally representative retrospective cohort study among adult ART enrollees during 2004-2010 to assess the effect of down-referral and spoke-initiation on rates of loss to follow-up (LTFU), death, and attrition (death or LTFU). Sixteen of 31 hubs were randomly selected using probability-proportional-to-size sampling. Seven selected facilities had initiated the hub-and-spoke model by study start. At these facilities, 1149 of 24,782 hub-initiated and maintained and 878 of 7722 down-referred or spoke-initiated patient records were randomly selected and analyzed. At the 9 hub-only facilities, 483 of 6638 records were randomly selected and analyzed. Multivariable proportional hazards regression was used to assess effect of down-referral (a time-varying covariate) and spoke-initiation on outcomes.


RESULTS
At ART initiation, median age was 35, 65% were female, and median CD4 count was 147 cells per microliter. Controlling for known confounders, down-referral was strongly protective against LTFU [adjusted hazard ratio (AHR) 0.38; 95% confidence interval (CI): 0.29 to 0.50] and attrition (AHR = 0.50; 95% CI: 0.34 to 0.76) but not mortality. Compared with hub-initiated and maintained patients, spoke-initiated patients had lower LTFU (AHR 0.59; 95% CI: 0.45 to 0.77) and attrition rates (AHR 0.60; 95% CI: 0.47 to 0.77), but not mortality.


CONCLUSIONS
Down-referral and spoke-initiation within a hub-and-spoke ART decentralization model were protective against LTFU and overall attrition and could facilitate future ART program expansion.
*Division of Global HIV/AIDS, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, GA; †ICAP, Mailman School of Public Health, Columbia University, New York, NY; ‡Ministry of Health, Government of the Kingdom of Swaziland, Mbabane, Swaziland; and §Division of Global HIV/AIDS, Center for Global Health, Centers for Disease Control and Prevention, Mbabane, Swaziland.
Andrew F
AF
Auld
Harrison
H
Kamiru
Charles
C
Azih
Andrew L
AL
Baughman
Harriet
H
Nuwagaba-Biribonwoha
Peter
P
Ehrenkranz
Simon
S
Agolory
Ruben
R
Sahabo
Tedd V
TV
Ellerbrock
Velephi
V
Okello
George
G
Bicego
D000328:Adult; D044966:Anti-Retroviral Agents / Q000008:administration & dosage*; D023241:Antiretroviral Therapy, Highly Active; D015331:Cohort Studies; D003695:Delivery of Health Care / Q000458:organization & administration*; D013541:Eswatini; D005260:Female; D015658:HIV Infections / Q000188:drug therapy*; D006302:Health Services Research; D006801:Humans; D059012:Lost to Follow-Up; D008297:Male; D055118:Medication Adherence; D008875:Middle Aged; D011247:Pregnancy; D012189:Retrospective Studies
D044966:Anti-Retroviral Agents