Improving antiretroviral therapy scale-up and effectiveness through service integration and decentralization

Amitabh B. Suthar, George W. Rutherford, Tara Horvath, Meg Caroline Doherty, Eyerusalem K. Negussie

Research output: Contribution to journalArticle

Abstract

BACKGROUND:: Current service delivery systems do not reach all people in need of antiretroviral therapy (ART). In order to inform the operational and service delivery section of the WHO 2013 consolidated antiretroviral guidelines, our objective was to summarize systematic reviews on integrating ART delivery into maternal, newborn, and child health (MNCH) care settings in countries with generalized epidemics, tuberculosis (TB) treatment settings in which the burden of HIV and TB is high, and settings providing opiate substitution therapy (OST); and decentralizing ART into primary health facilities and communities. DESIGN:: A summary of systematic reviews. METHODS:: The reviewers searched PubMed, Embase, PsycINFO, Web of Science, CENTRAL, and the WHO Index Medicus databases. Randomized controlled trials and observational cohort studies were included if they compared ART coverage, retention in HIV care, and/or mortality in MNCH, TB, or OST facilities providing ART with MNCH, TB, or OST facilities providing ART services separately; or primary health facilities or communities providing ART with hospitals providing ART. RESULTS:: The reviewers identified 28 studies on integration and decentralization. Antiretroviral therapy integration into MNCH facilities improved ART coverage (relative risk [RR] 1.37, 95% confidence interval [CI] 1.05-1.79) and led to comparable retention in care. ART integration into TB treatment settings improved ART coverage (RR 1.83, 95% CI 1.48-2.23) and led to a nonsignificant reduction in mortality (RR 0.55, 95% CI 0.29-1.05). The limited data on ART integration into OST services indicated comparable rates of ART coverage, retention, and mortality. Partial decentralization into primary health facilities improved retention (RR 1.05, 95% CI 1.01-1.09) and reduced mortality (RR 0.34, 95% CI 0.13-0.87). Full decentralization improved retention (RR 1.12, 95% CI 1.08-1.17) and led to comparable mortality. Community-based ART led to comparable rates of retention and mortality. CONCLUSION:: Integrating ART into MNCH, TB, and OST services was often associated with improvements in ART coverage, and decentralization of ART into primary health facilities and communities was often associated with improved retention. Neither integration nor decentralization was associated with adverse outcomes. These data contributed to recommendations in the WHO 2013 consolidated antiretroviral guidelines to integrate ART delivery into MNCH, TB, and OST services and to decentralize ART.

Original languageEnglish (US)
JournalAIDS
Volume28
Issue numberSUPPL. 2
DOIs
StatePublished - 2014
Externally publishedYes

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Politics
Opiate Alkaloids
Therapeutics
Tuberculosis
Health Facilities
Confidence Intervals
Mortality
HIV
Guidelines

Keywords

  • antiretroviral therapy
  • coverage
  • decentralization
  • HIV
  • maternal neonatal and child health
  • methadone maintenance treatment
  • mortality
  • opiate substitution therapy
  • retention
  • systematic review
  • tuberculosis

ASJC Scopus subject areas

  • Immunology and Allergy
  • Immunology
  • Infectious Diseases
  • Medicine(all)

Cite this

Improving antiretroviral therapy scale-up and effectiveness through service integration and decentralization. / Suthar, Amitabh B.; Rutherford, George W.; Horvath, Tara; Doherty, Meg Caroline; Negussie, Eyerusalem K.

In: AIDS, Vol. 28, No. SUPPL. 2, 2014.

Research output: Contribution to journalArticle

Suthar, Amitabh B. ; Rutherford, George W. ; Horvath, Tara ; Doherty, Meg Caroline ; Negussie, Eyerusalem K. / Improving antiretroviral therapy scale-up and effectiveness through service integration and decentralization. In: AIDS. 2014 ; Vol. 28, No. SUPPL. 2.
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AU - Rutherford, George W.

AU - Horvath, Tara

AU - Doherty, Meg Caroline

AU - Negussie, Eyerusalem K.

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N2 - BACKGROUND:: Current service delivery systems do not reach all people in need of antiretroviral therapy (ART). In order to inform the operational and service delivery section of the WHO 2013 consolidated antiretroviral guidelines, our objective was to summarize systematic reviews on integrating ART delivery into maternal, newborn, and child health (MNCH) care settings in countries with generalized epidemics, tuberculosis (TB) treatment settings in which the burden of HIV and TB is high, and settings providing opiate substitution therapy (OST); and decentralizing ART into primary health facilities and communities. DESIGN:: A summary of systematic reviews. METHODS:: The reviewers searched PubMed, Embase, PsycINFO, Web of Science, CENTRAL, and the WHO Index Medicus databases. Randomized controlled trials and observational cohort studies were included if they compared ART coverage, retention in HIV care, and/or mortality in MNCH, TB, or OST facilities providing ART with MNCH, TB, or OST facilities providing ART services separately; or primary health facilities or communities providing ART with hospitals providing ART. RESULTS:: The reviewers identified 28 studies on integration and decentralization. Antiretroviral therapy integration into MNCH facilities improved ART coverage (relative risk [RR] 1.37, 95% confidence interval [CI] 1.05-1.79) and led to comparable retention in care. ART integration into TB treatment settings improved ART coverage (RR 1.83, 95% CI 1.48-2.23) and led to a nonsignificant reduction in mortality (RR 0.55, 95% CI 0.29-1.05). The limited data on ART integration into OST services indicated comparable rates of ART coverage, retention, and mortality. Partial decentralization into primary health facilities improved retention (RR 1.05, 95% CI 1.01-1.09) and reduced mortality (RR 0.34, 95% CI 0.13-0.87). Full decentralization improved retention (RR 1.12, 95% CI 1.08-1.17) and led to comparable mortality. Community-based ART led to comparable rates of retention and mortality. CONCLUSION:: Integrating ART into MNCH, TB, and OST services was often associated with improvements in ART coverage, and decentralization of ART into primary health facilities and communities was often associated with improved retention. Neither integration nor decentralization was associated with adverse outcomes. These data contributed to recommendations in the WHO 2013 consolidated antiretroviral guidelines to integrate ART delivery into MNCH, TB, and OST services and to decentralize ART.

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KW - maternal neonatal and child health

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KW - opiate substitution therapy

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KW - systematic review

KW - tuberculosis

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