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Comparative Study
. 2011 Oct 23;25(16):2027-36.
doi: 10.1097/QAD.0b013e32834b6480.

Outcomes of stable HIV-positive patients down-referred from a doctor-managed antiretroviral therapy clinic to a nurse-managed primary health clinic for monitoring and treatment

Alana T Brennan  1 , Lawrence Long, Mhairi Maskew, Ian Sanne, Imogen Jaffray, Patrick MacPhail, Matthew P Fox
Affiliations
Comparative Study

Outcomes of stable HIV-positive patients down-referred from a doctor-managed antiretroviral therapy clinic to a nurse-managed primary health clinic for monitoring and treatment

Alana T Brennan et al. AIDS. .

Abstract

Objective: To compare clinical, immunologic and virologic outcomes among stable HIV-positive patients down-referred to a nurse-managed primary healthcare clinic (PHC) for treatment maintenance to those who remained at a doctor-managed treatment-initiation site.

Design: We conducted a matched cohort analysis among stable HIV patients at the Themba Lethu Clinic in Johannesburg, South Africa. Eligible patients met the criteria for down-referral [undetectable viral load <10 months, antiretroviral therapy (ART) >11 months, CD4 cell count ≥200 cells/μl, stable weight and no opportunistic infections], regardless of whether they were down-referred to a PHC for treatment maintenance between February 2008 and January 2009. Patients were matched 1 : 3 (down-referred : treatment-initiation) using propensity scores.

Methods: We calculated rates and hazard ratios (HRs) for the effect of down-referral on loss to follow-up (LTFU) and mortality and the relative risk of down-referral on viral rebound by 12 months of follow-up.

Results: Six hundred and ninety-three down-referred patients were matched to 2079 treatment-initiation patients. Two (0.3%) down-referred and 32 (1.5%) treatment-initiation patients died, 10 (1.4%) down-referred and 87 (4.2%) treatment-initiation patients were lost, and 22 (3.3%) down-referred and 100 (5.6%) treatment-initiation patients experienced viral rebound by 12 months of follow-up. After adjustment, patients down-referred were less likely to die [hazard ratio (HR) 0.2, 95% confidence interval (CI) 0.04-0.8], become LTFU (HR 0.3, 95% CI 0.2-0.6) or experience viral rebound (relative risk 0.6, 95% CI 0.4-0.9) than treatment-initiation patients during follow-up.

Conclusion: The utilization of nurse-managed PHCs for treatment maintenance of stable patients could decrease the burden on specialized doctor-managed ART clinics. Patient outcomes for down-referred patients at PHCs appear equal, if not better, than those achieved at ART clinics among stable patients.

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Figures

Figure 1
Figure 1. Selection of study patients for an analysis of the effects of down-referral of stable HIV treatment patients in Johannesburg, South Africa
d4T, stavudine; 3TC, lamivudine; LPRr, lopinavir/ritonavir; AZT, zidovudine; ddI, didanosine
None
See this image and copyright information in PMC

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