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. 2012;7(10):e38044.
doi: 10.1371/journal.pone.0038044. Epub 2012 Oct 15.

Treatment initiation, program attrition and patient treatment outcomes associated with scale-up and decentralization of HIV care in rural Malawi

Megan McGuire  1 , Loretxu Pinoges, Rupa Kanapathipillai, Tamika Munyenyembe, Martha Huckabee, Simon Makombe, Elisabeth Szumilin, Annette Heinzelmann, Mar Pujades-Rodríguez
Affiliations

Treatment initiation, program attrition and patient treatment outcomes associated with scale-up and decentralization of HIV care in rural Malawi

Megan McGuire et al. PLoS One. 2012.

Abstract

Objective: To describe patient antiretroviral therapy (cART) outcomes associated with intensive decentralization of services in a rural HIV program in Malawi.

Methods: Longitudinal analysis of data from HIV-infected patients starting cART between August 2001 and December 2008 and of a cross-sectional immunovirological assessment conducted 12 (±2) months after therapy start. One-year mortality, lost to follow-up, and attrition (deaths and lost to follow-up) rates were estimated with exact Poisson 95% confidence intervals (CI) by type of care delivery and year of initiation. Association of virological suppression (<50 copies/mL) and immunological success (CD4 gain ≥100 cells/µL), with type of care was investigated using multiple logistic regression.

Results: During the study period, 4322 cART patients received centralized care and 11,090 decentralized care. At therapy start, patients treated in decentralized health facilities had higher median CD4 count levels (167 vs. 130 cell/µL, P<0.0001) than other patients. Two years after cART start, program attrition was lower in decentralized than centralized facilities (9.9 per 100 person-years, 95% CI: 9.5-10.4 vs. 20.8 per 100 person-years, 95% CI: 19.7-22.0). One year after treatment start, differences in immunological success (adjusted OR=1.23, 95% CI: 0.83-1.83), and viral suppression (adjusted OR=0.80, 95% CI: 0.56-1.14) between patients followed at centralized and decentralized facilities were not statistically significant.

Conclusions: In rural Malawi, 1- and 2-year program attrition was lower in decentralized than in centralized health facilities and no statistically significant differences in one-year immunovirological outcomes were observed between the two health care levels. Longer follow-up is needed to confirm these results.

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Conflict of interest statement

Competing Interests: The authors have declared that no competing interests exist.

Figures

Figure 1
Figure 1. Trends in cART enrollment in centralized and decentralized sites, Chiradzulu, Malawi, 2001–2008.
Figure 2
Figure 2. Evolution of mortality, lost to follow-up, and attrition 1 year after cART start.
Figure 3
Figure 3. Evolution of rates of mortality, lost to follow-up, and attrition after cART initiation.
See this image and copyright information in PMC

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