Outcomes

Anticipated absolute effects

Relative effect
(95% CI)

No of Participants
(studies)

Quality of the evidence
(GRADE)

Risk without decentralization of HIV treatment (Control)

Risk with decentralization of HIV treatment (95% CI)

Partial decentralisation: Antiretroviral therapy initiated in a hospital, maintained at a health centre for HIV infected patients

Death or loss to care (Follow up 12 months)

22 per 100

10 fewer per 100 (from 5 to 14 fewer)

OR 0.69 (0.66-0.73)

39,090 (4)

moderate^1,2,3

Lost to care (Follow up 12 months)⁴

13 per 100

6 fewer per 100 (from 4 to 7 fewer)

OR 0.67 (0.63-0.71)

39,090 (4)

Deaths (Follow up 12 months)⁶

8 per 100

5 fewer per 100 (from 1 to 7 fewer)

OR 0.79 (0.73-0.85)

39,090 (4)

Full decentralisation - initiation and maintenance in health centre

Lost to care (Follow up 12 months)

27 per 100

18.91 fewer per 100 (from 12 to 22 fewer)

OR 0.36 (0.34-0.38)

56,360 (4)

Deaths (Follow up 12 months)

10 per 100

1 more per 100 (from 4 fewer to 9 more)

OR 1.10 (1.06-1.19)

55,099 (4)

GRADE Working Group grades of evidence
High: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low: We are very uncertain about the estimate.

1.        No serious inconsistency. All four studies report a decrease in attrition at 12 months.

2.        Not downgraded for indirectness. The studies included adults (two studies), children (1 study) or both (1 study); and were conducted in sub-Saharan Africa (South Africa, Malawi).

3.        Upgraded by 1 for large effect size. The effect estimate indicated a 54% decrease in attrition in the decentralised group.

4.        Adjusted rates for Brennan 2011, Chan 2010 and Fatti 2010 are consistent with the crude proportions reported here. In Brennan 2011, the adjusted hazard ratio was 0.3 (95% CI 0.2 to 0.6)/ 100 person years indicating better outcomes at the health centre. Chan 2010 reported an adjusted odds ratio of 0.48 (95% CI 0.4 to 0.58) indicating better outcomes at the health centre. Fatti 2010 presented the results inversing the site of risk, the adjusted hazard ratio was 2.19 (1.94 to 2.24) indicating greater problems with patients failing to attend the hospital.

5.        No serious inconsistency. Three of the four studies show benefit with varied effect sizes (39%. 51% and 66% reduction in patients lost to care), the smallest study reports no difference in clinic follow-up at 12 months.

6.        Adjusted rates for Brennan 2011, Chan 2010 and Fatti 2010 are consistent with the crude proportions reported here. In Brennan 2011, the adjusted hazard ratio was 0.2 (95% CI 0.04 to 0.8)/ 100 person years indicating better outcomes at the health centre. Chan 2010 reported an adjusted odds ratio of 0.19 (95% CI 0.15 to 0.25) indicating better outcomes at the health centre. Fatti 2010 presented the results inversing the site of risk, the adjusted hazard ratio was 1.6 (95% CI 1.3 to 1.99) indicating relatively increased risk of death in patients attending the hospital.

7.        Not downgraded for methodological limitations. For one included study (Fatti 2010), the health centre group had balanced CD4 cell counts, but more severe illness - 79% had WHO clinical stage III or IV disease compared with 58% in the hospital group. However, this would tend to favour the hospital group so we did not downgrade on baseline imbalance.

8.        No serious inconsistency. All four studies show decrease in death at 12 months with varied effect sizes (10%, 74%, 77% and 81% reductions).

9.        Not upgraded for large effect size, despite large effect size and narrow confidence interval, this review is not aiming to explore whether decentralisation decreases death, rather excluding that it increases death. The model of care down refers healthier patients for maintenance therapy, generally sicker patients remain at the hospital setting, this therefore favours decentralisation.

10.     Not downgraded for indirectness. The studies included adults (3 studies) or adults and children (1 study); and were conducted in sub-Saharan Africa (South Africa, Malawi and Ethiopia). This model of care is probably applicable in better resourced settings where basic levels of healthcare are likely to be better resourced, favouring decentralisation.

11.     Not downgraded for risk of bias. Four retrospective cohorts provided data. Although there were differences in their baseline health status (Bedelu 2008, Massaquoi 2009 and McGuire 2012 included sicker patients at the hospital), this study limitation is not expected to impact on the attendance at the clinic.

12.     Not downgraded for inconsistency. All four studies showed substantially better clinic attendance with decentralisation, however, the effect sizes varied, 24%, 63%, 80% and 89% reductions.

13.     Upgraded by 1 for large effect size . The effect size indicates a 70% lower rate of failure to attend clinic follow-up at the health centre compared to hospital.

14.     Downgraded by 1 for methodological limitations. Bedelu 2008, McGuire 2013 and Massaquoi 2009 included sicker patients at the hospital setting, Assefa has unknown baseline risk as other baseline characteristics were not reported. This bias would tend to favour therapy provided at the health centre.

15.     Downgraded for inconsistency. There is qualitative heterogeneity, Bedelu 2008, Massaquoi 2009 and McGuire 2013 include sicker patients at the hospital, yet only McGuire showed increased death in that setting. Therefore the inconsistency is unexplained.

16.     Downgraded by 1 for imprecision. Although the sample sizes are large and event rates are high, the confidence interval is wide including both appreciable benefit and harm.

Findings

Interpretation

Equity – Which of the PROGRESS groups examined

All the studies were conducted in low- and middle-income countries. All the studies were conducted in African countries except one study in Thailand.

The results of this review are applicable for HIV patients in other LMIC settings.  

Participants included both children and adults.

Decentralisation is effective in reducing lost to follow up rates for children as well as adults.

Participants were located in both urban and rural locations.

Decentralisation improves access to HIV treatment for patients living in urban and rural communities.

Equity Applicability

All of the included studies were conducted in low- and middle-income countries and included both adult and children participants.

Decentralisation of HIV treatment is effective for low- and middle-income countries and for children and adults. The benefits of decentralization include reduced costs and time requirements associated with traveling to treatment, and reduced costs of treatment. It also improved patient retention so that more patients continued their treatment and fewer patients were lost to follow up.

The interventions were successful however they had support systems and resources to ensure delivery of training and supervision as well as ensuring the availability of computer-aided checklists and decision aids. 

To ensure consistent quality of care and feasibility decentralisation requires strong support structures. Policy makers and program managers need to ensure adequate training for community health workers and supervision and support. Referral systems need to be in place to ensure patients who experience complications receive appropriate care.

Cost-equity

The review looked at several studies that provided data indicating reduced costs for both patients and services when patients attend facilities closer to their homes.

Decentralisation has many cost-equity benefits. HIV treatment services provided in health centres reduces the cost of treatment for the patient. Decentralisation was also found to reduce the cost for service provision.

Monitoring & Evaluation for PROGRESS Groups

The most effective packages of care that best suit different settings has not been determined, various settings and provide high quality care at decentralised sites. However, all the studies showed positive effects of decentralisation on HIV treatment.

Further research is needed to determine the overall outcomes and costs of decentralisation of HIV treatment to other levels of the health system, as well as full decentralization.

The feasibility and effectiveness of decentralization for other treatments could be explored to reduce barriers to access.