title: Clinic-level factors influencing patient outcomes on antiretroviral therapy in primary health clinics in South Africa.
abstract: OBJECTIVE
  To explore which clinic-level factors influence treatment outcomes in a multisite antiretroviral therapy (ART) programme in South Africa.
  
  
  METHODS
  Retrospective cohort study using 36 clinics.
  
  
  METHODS
  We used random effects modelling to investigate clinic-level factors influencing ART outcomes, adjusting for patient-level factors and accounting for clustering at clinic level. Outcomes were unsuppressed viral load (>400 copies/ml) at 24 months after ART start and time to loss to follow-up.
  
  
  RESULTS
  At clinic level, the mean proportion of patients with unsuppressed viral load at 24 months was 16% (range 8-33%). Loss to follow-up was also highly variable across clinics ranging from 3.5 to 23.4/100 person-years. Unsuppressed viral load was associated with a lower doctor-patient ratio [for every 500 patients, compared with >2.6 doctors: <0.7 doctors: adjusted odds ratio (OR) 1.52, 95% confidence interval (CI) 1.04-2.21; 0.7-2.6 doctors, OR 1.33, CI 0.91-1.93, P trend 0.04] after adjustment for patient factors. Combinations of psychosocial support interventions were weakly associated with reduced loss to follow-up [>6 interventions vs. <4 interventions: hazard ratio 0.39 (CI 0.15 - 1.04), P = 0.11]. Flexibility of services, integration of services, staff motivation, staff leadership and location of clinic were not consistently associated with improved outcomes.
  
  
  CONCLUSIONS
  The dominant clinic-level influences on patient outcomes were doctor : patient ratio, and combination interventions to reduce loss to follow-up. Further research is needed to define optimum staffing levels that are required to roll out ART and the combination intervention that is most effective to reduce loss to follow-up.
authors.affiliation: aThe Aurum Institute, Johannesburg, South Africa bLondon School of Hygiene & Tropical Medicine, London, United Kingdom cSchool of Public Health, University of Witwatersrand, Johannesburg dUniversity of Western Cape, South Africa.
authors.forename: Salome
authors.initials: S
authors.lastname: Charalambous
authors.forename: Alison D
authors.initials: AD
authors.lastname: Grant
authors.forename: Gavin J
authors.initials: GJ
authors.lastname: Churchyard
authors.forename: Rachel
authors.initials: R
authors.lastname: Mukora
authors.forename: Helen
authors.initials: H
authors.lastname: Schneider
authors.forename: Katherine L
authors.initials: KL
authors.lastname: Fielding
mesh_terms: D000328:Adult; D000368:Aged; D000554:Ambulatory Care Facilities; D044966:Anti-Retroviral Agents / Q000627:therapeutic use*; D023241:Antiretroviral Therapy, Highly Active / Q000379:methods*; D005260:Female; D015658:HIV Infections / Q000188:drug therapy*; D006298:Health Services Administration; D006801:Humans; D059012:Lost to Follow-Up; D008297:Male; D008875:Middle Aged; D011320:Primary Health Care; D012189:Retrospective Studies; D013019:South Africa; D016896:Treatment Outcome; D019562:Viral Load; D055815:Young Adult
chemical_list: D044966:Anti-Retroviral Agents