Decentralization of HIV care and treatment services in Kenya

Decentralization of HIV care and treatment services in Central Province, Kenya. 

Reidy W, Sheriff M, Wang C, Hawken M, Koech E, Elul B, Kimanga D, Abrams E; for the Identifying Optimal Models of HIV Care in Africa: Kenya Consortium. J Acquir Immune Defic Syndr. 2014 Jun 26. [Epub ahead of print].

Background: Since 2006, the government of Kenya began decentralizing HIV care from secondary health facilities (SHF) to an expanded network including primary health facilities (PHF). We evaluated the impact of this strategy on enrollment, care, and outcomes among adult patients in Central Province, Kenya from 2006 to 2010.

Methods: We analyzed electronic patient-level data for 26 690 patients at 15 SHF and 22 PHF. Enrollment, patient and facility characteristics, and patterns in CD4+ testing, WHO staging, and ART initiation were compared between SHF and PHF. Survival analysis was used to estimate cumulative death and loss to follow-up (LTF) rates in PHF and SHF. Multivariate competing risks regression and Cox proportional hazards models were constructed to identify correlates of LTF and death.

Results: Enrollment in PHF increased mainly between 2007 and 2009, representing 5% and 25% of all new enrollments, respectively. CD4+ test provision and WHO staging, time to ART initiation, and CD4+ count at ART initiation were for the most part similar between PHF and SHF. In multivariate analyses, pre-ART patients enrolled in PHF had a lower risk of LTF than those enrolled in SHF (SHR=0.77, 95% CI: 0.61-0.96). No differences in risk of death among pre-ART patients, or in LTF or death among ART patients were observed.

Conclusion: Enrollment at PHF increased substantially during the period; death rates were comparable between PHF and SHF, while LTF among pre-ART patients was lower at PHF. This suggests that decentralization can be a successful strategy for expanding HIV care.

Abstract access 

Editor’s notes: As with many other countries in sub-Saharan Africa, Kenya has chosen the strategy of decentralisation of HIV services to peripheral health centres, to close the treatment gap.

The authors of this paper compared enrolment, people’ characteristics, and outcomes among nearly 27 000 people in HIV care at primary and secondary health facilities between 2006 and 2010. Over this period, the proportion of people living with HIV enrolled in care at primary health facilities increased substantially. People at primary health facilities had a somewhat healthier profile. This was possibly due to self-selection where sicker people refer themselves to secondary health facilities. No differences in mortality and loss to follow-up among people on antiretroviral therapy (ART) were observed between primary and secondary health facilities. Retention in care among people not yet on ART can be particularly challenging. So the finding that people in primary health facilities experienced lower loss to follow-up rates compared to people using secondary health facilities is useful evidence in support of decentralised care.

Decentralisation of care sometimes raises concerns that the quality of care may be less good when delivered by less specialised staff. This study compared quality of services such as assessment of people for ART eligibility and time to ART initiation. The authors found similar quality of services at primary and secondary health facilities. Interestingly people at primary health facilities were initiated earlier on ART after HIV diagnosis, possibly due to more frequent assessment of ART eligibility at these centres.

This large study is a useful addition to the evidence base supporting decentralised HIV care, with no evidence of loss of quality.

Health care delivery
Africa
Kenya
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