Agaba Patricia A, Genberg Becky L, Sagay Atiene S, Agbaji Oche O, Meloni Seema T, Dadem Nancin Y, Kolawole Grace O, Okonkwo Prosper, Kanki Phyllis J, Ware Norma C
Faculty of Medical Sciences, University of Jos, Nigeria.
Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA.
J AIDS Clin Res. 2018;9(2). doi: 10.4172/2155-6113.1000756. Epub 2018 Feb 13.
Differentiated care refers collectively to flexible service models designed to meet the differing needs of HIV-infected persons in resource-scarce settings. Decentralization is one such service model. Retention is a key indicator for monitoring the success of HIV treatment and care programs. We used multiple measures to compare retention in a cohort of patients receiving HIV care at "hub" (central) and "spoke" (decentralized) sites in a large public HIV treatment program in north central Nigeria.
This retrospective cohort study utilized longitudinal program data representing central and decentralized levels of care in the Plateau State Decentralization Initiative, north central Nigeria. We examined retention with patient- level (retention at fixed times, loss-to-follow-up [LTFU]) and visit-level (gaps-in-care, visit constancy) measures. Regression models with generalized estimating equations (GEE) were used to estimate the effect of decentralization on visit-level measures. Patient-level measures were examined using survival methods with Cox regression models, controlling for baseline variables.
Of 15,650 patients, 43% were enrolled at the hub. Median time in care was 3.1 years. Hub patients were less likely to be LTFU (adjusted hazard ratio (AHR)=0.91, 95% CI: 0.85-0.97), compared to spoke patients. Visit constancy was lower at the hub (-4.5%, 95% CI: -3.5, -5.5), where gaps in care were also more likely to occur (adjusted odds ratio=1.95, 95% CI: 1.83-2.08).
Decentralized sites demonstrated better retention outcomes using visit-level measures, while the hub achieved better retention outcomes using patient-level measures. Retention estimates produced by incorporating multiple measures showed substantial variation, confirming the influence of measurement strategies on the results of retention research. Future studies of retention in HIV care in sub-Saharan Africa will be well-served by including multiple measures.
差异化护理总体上指的是为满足资源匮乏地区艾滋病毒感染者不同需求而设计的灵活服务模式。去中心化就是这样一种服务模式。留存率是监测艾滋病毒治疗和护理项目成功与否的关键指标。我们采用多种衡量方法，比较了尼日利亚中北部一个大型公共艾滋病毒治疗项目中，在“中心”（集中式）和“分支”（去中心化）地点接受艾滋病毒护理的一组患者的留存率。
这项回顾性队列研究利用了尼日利亚中北部高原州去中心化倡议中代表集中式和去中心化护理水平的纵向项目数据。我们通过患者层面（固定时间的留存率、失访率[LTFU]）和就诊层面（护理间隙、就诊稳定性）的衡量方法来研究留存率。使用广义估计方程（GEE）的回归模型来估计去中心化对就诊层面衡量指标的影响。采用Cox回归模型的生存方法来研究患者层面的衡量指标，并对基线变量进行控制。
在15650名患者中，43%在中心地点登记入组。护理的中位时间为3.1年。与分支地点的患者相比，中心地点的患者失访的可能性较小（调整后的风险比[AHR]=0.91，95%置信区间：0.85 - 0.97）。中心地点的就诊稳定性较低（-4.5%，95%置信区间：-3.5，-5.5），在该地点护理间隙也更有可能出现（调整后的优势比=1.95，95%置信区间：1.83 - 2.08）。
去中心化地点在就诊层面衡量指标上显示出更好的留存结果，而中心地点在患者层面衡量指标上取得了更好的留存结果。纳入多种衡量方法得出的留存率估计值显示出很大差异，证实了测量策略对留存率研究结果的影响。撒哈拉以南非洲地区未来关于艾滋病毒护理留存率的研究采用多种衡量方法将大有裨益。
