Background
Methods
Literature search strategy
Study selection
Data extraction and data synthesis
Results
Study characteristics
First author, year | Study design | Study participant | Study location/country | Study objective | Model of ART services | Additional resources provided | Study duration/period | Number of patient enrolled | Outcomes of interest | |
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Primary | Secondary | |||||||||
Assefa, 2011 [30] | Mix method: retrospective cohort and qualitative study | HIV patient started ART at health facilities providing ART services | 55 health facilities 25 health centers and 30 hospitals representing different regions of Ethiopia | To evaluate outcomes of ART services at health centers vs hospital | ART services led by health officer, nurses and CHWs at health center | Community health workers: adherence counseling, defaulter tracking referral and linkage between facilities | Sep 2006–Mar 2009 | 6206 at health centers; 31,929 at hospitals | Proportion of patient with CD4 count documented Stakeholder’s perspectives on new decentralized model of care | |
Bedelu, 2007 [17] | Retrospective cohort | Adult HIV patient | Primary care clinics and hospitals/Lusikisiki, South Africa (SA) | To assess the effect of decentralization and task-shifting on treatment outcomes | ART service led by nurses at health clinic | MSF supported through mobile team visit, training/mentoring of nurse; engage community through support groups | Apr 2004–Apr 2006 | 1025 (595 at clinic; 430 at hospital) | Proportion of patient with CD4 count and VR data documented | |
Boulle, 2010 [19] | Retrospective cohort | Adult treatment naïve HIV patient ≥14 years old | HIV treatment program at three public primary care clinics (PHC) Khayelitsha, SA | To describe outcomes of ART program for adult up to 5 years | Nurse based care with stable patients seen by a nurse 2–3 monthly | Program established/supported by MSF | 2001–2007 | 7323 | Proportion of patient with CD4 count and viral load data available | Proportion of patient reported treatment failure; % patient switch to 2nd line ART |
Brennan, 2011 [16] | Retrospective cohort | ART naive patient >18 years old | Urban HIV clinic and local PHC in Johannesburg SA | To compare one year outcomes between patient down-referred and maintained at central clinic | ART initiated at hospital and then follow-up at PHC by nurse | Nurse received down-reference training; supervise by doctor, plus advice by electronic treatment algorithm | Apr 2004–Sep 2008 | 2772 | Proportion of patient with 12 month CD4 and VL available | |
Fatti, 2010 [41] | Retrospective cohort | ART naïve adult patient >16 years | 59 public facilities: 47 PHCs, nine district and three regional hospitals in four provinces of SA | To compare treatment outcomes at different levels of health system (primary health care, district and regional hospital) | ART services led by doctor at different levels | Community-based adherence counselor; all sites supported by NGO (absolute return to kids) with free services to HIV patients | Dec 2004–Dec 2007 | 29,203 | Proportion of patient with viral load results | |
Fairall, 2012 [13] | Randomized control trial | Adult patient who had received ART for at least 6 months and were on ART at time of enrollment | 31 clinics (16 intervention and 15 control) in free state of SA | To assess effects of task-shifting program on treatment outcomes | ART service led by nurse at primary care clinics (intervention) vs doctor at hospital OPC (control) | Outreach training for nurses with doctor support | Jan 2008–Jun 2010 | 3029 (intervention) 3202 (control) | Proportion of patient with VR data available | |
Humphreys, 2010 [27] | Prospective cohort | Adult patient on ART at least 4 weeks CD4 >100 | Primary care clinics and district hospital in rural Swaziland | To assess effect of nurse led primary care based ART program | ART service led by nurse at primary care clinics vs doctor at hospital | Training for primary care nurses by hospital followed by monthly outreach support visits | Jan–Nov 2007 | 474 | Patient experience with primary based ART program | |
Hansudewe-chakul, 2012 [15] | Retrospective cohort | HIV infected children | Tertiary hospital and community hospital in rural Thailand | To assess effects of decentralization of pediatric HIV care model | ART initiated at tertiary hospital, monitored at community hospital | Training and mentoring for CH staffs; trained PLHIV: adherence, psychological support | Feb 2002–Mar 2008 | 410 | Proportion of patient with VL data recorded | |
Janssen, 2010 [21] | Prospective cohort | HIV patient <15 years on ART | Primary care clinics, KwaZulu-Natal, SA | To assess clinical outcomes of children in a decentralized model | Nurse/counselor led ART program | Home-based care program with nurse/community volunteer providing first aids, nutrition, adherence support at home | Jun 2004–Jun 2008 | 477 | Proportion of patients receiving CD4 and VL monitoring | |
Jobanputra, 2014 [26] | Retrospective cohort | HIV patient on ART | Primary health care clinics in rural poor Shiselweni region of Swaziland | To assess program quality, cost and outcomes of routine VL monitoring | Nurse led ART program | MSF support (laboratory equipment, reagent, training of staff) | Oct 2012–Mar 2013 | 5563 | Proportion of patients receiving routine VL monitoring | Reported treatment failure rate; % patient switch to 2nd line ART |
Labhardt, 2012 [29] | Retrospective cohort | HIV patient >16 years old on ART with at least three drugs | Two hospital and 12 health centers of Botha-Bothe ad Thaba-Tseka districts of Lesotho | To assess the effectiveness of decentralized ART program | Nurse led ART program | ART program supported by a Swiss NGO through the SolidarMed ART project | Jan 2008–Apr 2011 | 3747 | Availability of treatment monitoring tools at decentralized settings | |
Mutevedzi, 2010 [20] | Retrospective cohort | Adult patient >16 years old | 16 primary care clinic in rural SA | To describe and assess scale-up of decentralized HIV treatment program | ART initiated by doctor and monitored by nurse | Support for program provided by PEPFAR | Oct 2004–Sep 2008 | 3010 | Proportion of patient with VL data recorded | |
Rich, 2012 [22] | Retrospective cohort | HIV patient on ART | ART clinics at health centers in rural Rwanda | To assess clinical outcomes of HIV treatment program | Community-based ART program with directly observed ART and psychosocial supported provided by CHWs | Ongoing HIV education, nutritional assistance, travel allowance for clinic visits, diagnosis and treatment of TB; additional doctor/provider support | Jun 2005–Apr 2006 | 1041 | Proportion of patient with CD4 and VL monitoring data available | Proportion of patient change treatment regimen due to toxicity; % patient switch to 2nd line ART |
Selke, 2010 [14] | Randomized control trial | HIV patient, 18 years stable on ART at least 3 months | HIV clinic in rural health center of Kenya | To assess impact of task shifting | Nurse led ART service with home based visit by community care coordinator (CCCs) vs standard of care (no CCCs) | Electronic device support tool (PDA) for patient monitoring; program supported by USAID | Mar 2006–Apr 2008 | 208 (96 intervention; 112 control) | Proportion of patient monitored with clinical, immunological, virological data | |
Shumbusho, 2009 [24] | Retrospective cohort | HIV treatment-naïve adult patients | Three rural primary health centers in Rwanda | To evaluate results of pilot task-shifting model for ART service provision | Nurse centered ART services (initiation management and referral of complex cases | Additional personnel provided for intervention (specific number not reported) | Sep 2005–Mar 2008 | 1076 (641 pre-ART and 435 on ART) | Proportion of patient with CD4 count documented | Proportion of patient change treatment regimen due to toxicity; % patient switch to 2nd line ART |
Sanne, 2010 [25] | Randomized control trial | Adult HIV-1patient (>16 year old, CD4 <350 or previous AIDS defining illness; not pregnant) | Two primary health care sites in Cape town and Johannesbur, SA | To compare outcomes of nurse vs doctor management of ART | ART services led by nurses (vs doctor led): full decentralization | Not reported | Feb 2005–Jan 2009 | 812 | Proportion of patient reported drug toxicity | |
Uzodike, 2015 [18] | Cross-sectional | Adult HIV patient on ART | Primary healthcare (PHC) clinics in Kwazulu-Natal, SA | To assess monitoring and referral of patient on ART managed at PHC clinics | ART services led by nurses | Not reported | Jun 2011–Jun 2012 | 488 | Proportion of patients with CD4 VL monitoring data available | % patient reported virological failure |
Vogt, 2015 [23] | Retrospective cohort | HIV patient >18 years old initiated on ART at district hospital and rural health clinics (RHCs) | Beitbridge district hospital and six RHCs in Matabeleland South province, Zimbabwe | To compare coverage of CD4 testing between rural and urban HIV patient during 1st year of treatment | HIV care services provided by nurses at RHCs through weekly outreach visits | Services provision supported by MSF (MSF nurse and phlebotomy equipment) | Jan 2011–Dec 2012 | 2145 | Proportion of patients receiving CD4 testing | |
Walter, 2014 [12] | Before–after (decentralization) comparison | HIV adult patients initiated on ART at primary health centers | To compare treatment outcomes before and after decentralization | ART service led by nurses at primary health care center | Not reported | 2003–2006 (before) 2009–2011 (after) | 3936 (before); 13,505 (after) | Proportion of patient with CD4 count documented | ||
Georgeu, 2012 [28] | Qualitative | HIV patient, service providers (physician, nurse) | Primary health care clinics in free state of SA | To explore experience, perceptions of various stakeholders on implementation process of decentralization of ART services | ART service led by nurses | Not reported | Oct 2007–Jun 2008 | 16 FGDs, 26 in-depth and key informant interview | Implementing issues related to decentralization Stakeholder’s perspective on decentralization |
HIV viral load (VL) monitoring
First author, year | Follow-ups | Number of patient retained in care | Proportion of patient monitored for treatment response n (%) by # monitoring approaches | Laboratory testing services | Testing site | Notes | ||
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Virological | Immunological | Clinicala
| ||||||
Assefa, 2011 [30] | 6 months | Health center: 5072/6197 Hospital: 24,821/31,269 | Not report (NR) | 54% | NR | Not stated | Not stated | Number of patients received immunological monitoring with CD4 count documented was not reported. Data (proportion of patient monitored) was not reported separately for each level of care |
12 months | Health center: 3042/4022 Hospital: 17,037/23,039 | NR | 51% | |||||
24 months | Health center 650/856 Hospital : 4419/6595 | NR | 51% | |||||
Bedelu, 2007 [17] | 12 months | Health clinic: 482/595 Hospital: 289/430 | Health clinic: 296/482 (61.4%) Hospital: 41/289 (14.2%) | Health clinic: 348/482 (72.2%) Hospital: 81/289 (28%) | NR | Not stated | Not stated | |
Boulle, 2010 [19] | 1 year | 4512 | 3932/4512 (87%) | 3823/4512 (85%) | NR | CD4 and VL provided 6-monthly after staring ART | Not stated | VL: NucliScens EasyQHIV-1 assay CD4: single-platform panleucogating method Type of blood used not reported |
2 years | 2561 | 2198/2561 (86%) | 2108/2561 (82%) | |||||
3 years | 1235 | 983/1235 (79.6%) | 931/1235 (75.4%) | |||||
4 years | 458 | 351/458 (76.6%) | 341/458 (74.5%) | |||||
5 years | 191 | 148/191 (77.5%) | 127/191 (66.5%) | |||||
Brennan, 2011 [16] | 12 months | Hospital : 1958/2079 Primary health care: 681/693 | Hospital: 1774/1958 (90.6%) PHC 676/681 (99.2%) | PHC: 95% Hospital: 81% | Clinical monitor performed every 2 months by nurse at PHC; 6 monthly by doctor at hospital | CD4 and VL test measured every 6 month | Not stated | Inconsistency in data on % patients with CD4 and VL data available between text and table. Number of patients with 12 months CD4 count available not reported |
Fatti, 2010 [41] | 12 months | 11,960 | 6725 (56.2%) | NR | Patients attend monthly clinical checks | CD4 count and VL monitored 6 monthly for patient on treatment by SA NHL services | Off-site except for large hospital | Data (n/N) on proportion of patient received and had VL available was reported for all level of care |
24 months | 4029 | 2525 (62.6%) | ||||||
36 months | 545 | 342 (62.8%) | ||||||
Fairall, 2012 [13] | 12 months | Primary care: 2823/3029 Hospital: 2981/3202 | Primary care: 2582/2823 (91.5%) Hospital: 2656/2981 (89.1%) | NR | NR | Not stated | Not stated | |
Hansudewe-chakul, 2012 [15] | 12, 24, 36, 48 months (VL data available at baseline and at least 1 follow-up) | Community hospital: 154 Tertiary hospital : 133 | CH: 22/154 (14.3%) TH: 38/133 (28.6%) | NR | Clinical monitoring using CDC classification; | CD4% assessed 6 monthly, routine VL testing not available. VL measured at 12 month intervals for 48 months | Not stated | No time point specific provided for % patient with VL data available. Scheduled clinic visit 6 monthly at tertiary hospital |
Janssen, 2010 [21] | 6–12 months | 447 | 193/447 (43.2%) | CD4%: 310/447 (69.3%); CD4: 315/447 (70.5%) | NR | Laboratory tests (CD4, VL, Hemoglobin/albumin) repeated 6 monthly | VL testing at referral hospital (75 km away); other tests at local hospital | |
Jobanputra, 2014 [26] | 12 months | 5563 | 4767/5563 (86%) | NR | NR | VL measured annually using a Generic HIV VL platform (Biocentric) | VL testing at regional virology laboratory | |
Mutevedzi, 2010 [20] | 12 months | 2527/3010 | 758/2527 (30%) | NR | NR | CD4 count and VL measured every 6 months | VL testing at provincial lab | VL measured by Nucli-Sens Easy HIV-1 assay). Type of blood used not report |
Rich, 2012 [22] | 24 months | 926 | 275/926 (29.7%) | 710/926 (76.7%) | NR | CD4 count measured 6 monthly using BD fluorescence-activated cell sorting count system | Not stated | |
Selke, 2010 [14] | 12 months | Intervention: 87 Control: 102 | Intervention: 86/87 (99%) Control: 96/102 (94.1%) | Intervention: 87/87 (100%) Control: 96/102 (94.1%) | Intervention: 74/87 (85%) Control: 87/102 (85.3%) | VL and CD4 count obtained at initial and close out research visit. Additional CD4 count at 6 months | Not stated | |
Shumbusho, 2009 [24] | 6 months | 217 | NR | 193/217 (88.9%) | 83.4%: side effect screening at all visits (frequency not reported) | CD4 count measured every 6 month using BD FACS Count | District hospital laboratory | |
12 months | 123 | NR | 104/123 (84.5%) | |||||
18 months | 43 | NR | 31/43 (72.1%) | |||||
24 months | 10 | 10/10 (100%) | ||||||
Uzodike, 2015 [18] | Jun 2011 | 488 | 407/488 (83.4%) | 461/488 (94.5%) | 412/488 (84.4%) | CD4 and VL monitored 6 monthly | Not stated | Clinical monitoring carried out monthly by nurses |
Dec 2011 | 466/488 (95.5%) | 464/488 (95.1%) | NR | |||||
Jun 2012 | 444/488 (91.0%) | 430/488 (88.1%) | 381/488 (78%) | |||||
Vogt, 2015 [23] | 6 months | 1250 | NR | 194/1250 (15.5%) | 1250/2145 (58%) | Whole blood collected in EDTA tube for testing by BD Fascount and Partect Cyflow | District hospital laboratory | Data is presented for both hospital and RHCs |
12 months | 1199 | NR | 74/1199 (6.2%) | 1199/2145 (56%) | ||||
Walter, 2014 [12] | 6 months | 11,243 | NR | 5859 (52%) | NR | Not stated | Not stated | |
12 months | 8644 | 5160 (60%) | ||||||
18 months | 6467 | 4110 (64%) | ||||||
24 months | 4485 | 3201 (71%) |
Clinical and immunological monitoring
Toxicity monitoring
Secondary outcomes
Factors that influence the implementation and feasibility of decentralization
First author, year | Reported implementing issues/barriers for ART services under decentralized care from system perspective | Acceptability and reported quality of decentralized care from service provider and patient perspectives |
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Assefa, 2012 [30] | Policy: lack of regulation framework enabling nurse to perform tasks such as ARV prescription, monitoring of patients on ART Finance: high cost associated with training and monitoring quality of services Human resource: additional workload for nurse without increased remuneration/compensation; Community health workers were not permanent employee/formal health system | Patient’s perspective: Nurse led ART services was well accepted, help to reduce waiting time; provide appropriate counseling; combat stigma and discrimination in society and can help to provide opportunity for employment |
Georgeu, 2012 [28] | Workload, including paperwork increased significantly for nurses and other team members through broader human resource shortage and lack of capacity (e.g. data capturers performed basic nurse duties when nurse too busy, nurse dispensed when pharmacist not available) Increased number of patients on treatment further strained scare/inadequate human and physical resources of health system: insufficiently staff and resources; fragmented information, poor patient transport/referral system; unreliable drug supplies due to poor communication, transport between pharmacy/central dispensing unit and clinics | Nurses were comfortable, motivated, enthusiastic about opportunity to be directly involve in providing life-saving ART treatment Physicians reported mix attitude: majority support decentralization and nurse initiated ART but significant minority reported uncertainty about the ability of nurses to manage and refer complicate cases Patients were supportive of decentralization as it improved access to care, reduced travel time/cost but some wanting ART to remain a separate services and expressed preference toward physician services because of higher clinical status and only doctor can medically certify social grant—key source of income for people living with HIV/AIDS in South Africa |
Humphreys, 2010 [27] | Among patients interviewed in intervention group (received nurse led/primary care based ART services) 81% (25/31) were very satisfied 13% (4/31) were satisfied 3% (1/31) dissatisfied and 3% (1/31) very dissatisfied as compared to services at main hospital Reasons for satisfaction includes: reduced cost, services provided nearer to home, shorter queue and being treated better by staff. Reasons for dissatisfaction were lack of doctor and delay of service because team from hospital arrive late | |
Labhardt, 2012 [29] | CD4, VL and biochemistry were not available on site at decentralized settings Hemoglobin was available in 2/5 and 2/7 health centers of two studied districts |