Kredo Tamara, Ford Nathan, Adeniyi Folasade B, Garner Paul
South African Cochrane Centre, South African Medical Research Council, Tygerberg, South Africa.
Cochrane Database Syst Rev. 2013 Jun 27;2013(6):CD009987. doi: 10.1002/14651858.CD009987.pub2.
Policy makers, health staff and communities recognise that health services in lower- and middle-income countries need to improve people's access to HIV treatment and retention to treatment programmes. One strategy is to move antiretroviral delivery from hospitals to more peripheral health facilities or even beyond health facilities. This could increase the number of people with access to care, improve health outcomes, and enhance retention in treatment programmes. On the other hand, providing care at less sophisticated levels in the health service or at community-level may decrease quality of care and result in worse health outcomes. To address these uncertainties, we summarised the research studies examining the risks and benefits of decentralising antiretroviral therapy service delivery.
To assess the effects of various models that decentralised HIV treatment and care to more basic levels in the health system for initiating and maintaining antiretroviral therapy.
We conducted a comprehensive search to identify all relevant studies regardless of language or publication status (published, unpublished, in press, and in progress) from 1 January 1996 to 31 March 2013, and contacted relevant organisations and researchers. The search terms included 'decentralisation', 'down referral', 'delivery of health care', and 'health services accessibility'.
Our inclusion criteria were controlled trials (randomised and non-randomised), controlled-before and after studies, and cohorts (prospective and retrospective) in which HIV-infected people were either initiated on antiretroviral therapy or maintained on therapy in a decentralised setting in lower- and middle-income countries. We define decentralisation as providing treatment at a more basic level in the health system to the comparator.
Two authors applied the inclusion criteria and extracted data independently. We designed a framework to describe different decentralisation strategies, and then grouped studies against these strategies. Data were pooled using random-effects meta-analysis. Because loss to follow up in HIV programmes is known to include some deaths, we used attrition as our primary outcome, defined as death plus loss to follow-up. We assessed evidence quality with GRADE methodology.
Sixteen studies met the inclusion criteria, all but one were from Africa, comprising two cluster randomised trials and 14 cohort studies. Antiretroviral therapy started at a hospital and maintained at a health centre (partial decentralisation) probably reduces attrition (RR 0.46, 95% CI 0.29 to 0.71, 4 studies, 39 090 patients, moderate quality evidence). There may be fewer patients lost to care with this model (RR 0.55, 95% CI 0.45 to 0.69, low quality evidence).We are uncertain whether there is a difference in attrition for antiretroviral therapy started and maintained at a health centre (full decentralisation) compared to a hospital at 12 months (RR 0.70, 95% CI 0.47 to 1.02; four studies, 56 360 patients, very low quality evidence), but there are probably fewer patients lost to care with this model (RR 0.3, 95% CI 0.17 to 0.54, moderate quality evidence).When antiretroviral maintenance therapy is delivered at home by trained volunteers, there is probably no difference in attrition at 12 months (RR 0.95, 95% CI 0.62 to 1.46, two trials, 1453 patients, moderate quality evidence).
AUTHORS' CONCLUSIONS: Decentralisation of HIV care aims to improve patient access and retention in care. Most data were from good quality cohort studies but confounding between site of treatment and outcomes cannot be excluded. Nevertheless, this review found that attrition appears to be lower in partial decentralisation models of treatment, where antiretrovirals were started at hospital and continued in the health centre; with antiretroviral drugs started and continued at health centres, no difference in attrition was detected, but there were fewer patients lost to care. For antiretroviral therapy provided at home by trained volunteers, no difference in outcomes were detected when compared to facility-based care.
政策制定者、卫生工作人员和社区都认识到，低收入和中等收入国家的卫生服务需要改善人们获得艾滋病毒治疗的机会，并提高治疗方案的留存率。一种策略是将抗逆转录病毒药物的发放从医院转移到更基层的卫生机构，甚至扩展到卫生机构之外。这可以增加获得护理的人数，改善健康结果，并提高治疗方案的留存率。另一方面，在卫生服务的较低层级或社区层面提供护理可能会降低护理质量，并导致更差的健康结果。为了解决这些不确定性，我们总结了评估抗逆转录病毒治疗服务下放的风险和益处的研究。
评估在卫生系统中，将艾滋病毒治疗和护理下放到更基层水平以启动和维持抗逆转录病毒治疗的各种模式的效果。
我们进行了全面检索，以识别1996年1月1日至2013年3月31日期间所有相关研究，无论其语言或发表状态（已发表、未发表、即将发表和正在进行），并联系了相关组织和研究人员。检索词包括“权力下放”“向下转诊”“卫生保健提供”和“卫生服务可及性”。
我们的纳入标准是对照试验（随机和非随机）、前后对照研究以及队列研究（前瞻性和回顾性），其中艾滋病毒感染者在低收入和中等收入国家的分散环境中开始接受抗逆转录病毒治疗或维持治疗。我们将权力下放定义为在卫生系统中比对照更基层的水平提供治疗。
两位作者独立应用纳入标准并提取数据。我们设计了一个框架来描述不同的权力下放策略，然后根据这些策略对研究进行分组。使用随机效应荟萃分析汇总数据。由于已知艾滋病毒项目中的失访包括一些死亡情况，我们将损耗作为主要结局，定义为死亡加失访。我们使用GRADE方法评估证据质量。
16项研究符合纳入标准，除一项外均来自非洲，包括两项整群随机试验和14项队列研究。在医院开始抗逆转录病毒治疗并在卫生中心维持（部分权力下放）可能会降低损耗（风险比0.46，95%置信区间0.29至0.71，4项研究，39090名患者，中等质量证据）。采用这种模式失访的患者可能更少（风险比0.55，95%置信区间0.45至0.69，低质量证据）。我们不确定在卫生中心（完全权力下放）开始并维持的抗逆转录病毒治疗与在医院进行12个月相比，损耗是否存在差异（风险比0.70，95%置信区间0.47至1.02；4项研究，56360名患者，极低质量证据），但采用这种模式失访的患者可能更少（风险比0.3，95%置信区间0.17至0.54，中等质量证据）。当由经过培训的志愿者在家中提供抗逆转录病毒维持治疗时，12个月时的损耗可能没有差异（风险比0.95，95%置信区间0.62至1.46，两项试验，1453名患者，中等质量证据）。
艾滋病毒护理的权力下放旨在改善患者获得护理的机会和护理留存率。大多数数据来自高质量的队列研究，但不能排除治疗地点与结局之间的混杂因素。尽管如此，本综述发现，在部分权力下放模式中，即在医院开始抗逆转录病毒治疗并在卫生中心继续治疗，损耗似乎较低；在卫生中心开始并继续使用抗逆转录病毒药物，未检测到损耗有差异，但失访的患者更少。对于由经过培训的志愿者在家中提供抗逆转录病毒治疗，与基于机构的护理相比，未检测到结局有差异。
