Decentralised paediatric HIV care in Ethiopia: a comparison between outcomes of patients managed in health centres and in a hospital clinic

Abstract

Background: In order to increase access to antiretroviral therapy (ART) in HIV-infected children, paediatric HIV care has been introduced in health centres in Ethiopia, where patients are managed by health professionals with limited training.

Objective: To compare outcomes of paediatric HIV care in hospital and health centre clinics and to determine risk factors for death and loss to follow-up (LTFU).

Design: Retrospective comparison of patient characteristics and outcomes among children managed in a public hospital and all five public health centres in the uptake area.

Results: Among 1,960 patients (health centres 572, hospital clinic 1,388), 34% were lost to follow-up, 2% died, 14% were transferred out, and 46% remained in care. Children initiating ART in the hospital clinic had lower median CD4 cell counts (age <1 year: 575 vs. 1,183 cells/mm³, p=0.024; age 1-5 years: 370 vs. 598 cells/mm³, p<0.001; age >5 years: 186 vs. 259 cells/mm³, p<0.001), and a higher proportion were <1 year of age (22% vs. 15%, p=0.025). ART initiation rates and retention in care were similar between children managed in health centres and in the hospital clinic (36% vs. 37% and 47% vs. 46%, respectively). Among patients starting ART, mortality was associated with age <1 year [hazard ratio (HR) 12.0; 95% confidence interval (CI): 3.5, 41]. LTFU was associated with CD4 cell counts <350 cells/mm³ (HR 1.8; 95% CI: 1.2, 3.0), weight-for-age z-scores below -4 (HR 2.8; 95% CI: 1.4, 5.6), and age <5 years (1-5 years: HR 1.6; 95% CI: 1.0, 2.5; <1 year: HR 3.3; 95% CI: 1.6, 6.6).

Conclusions: Outcomes of HIV care were similar for Ethiopian children managed in a hospital clinic or in health centres. However, patients treated at the hospital clinic had characteristics of more advanced disease. Rates of LTFU were high in both types of health facility.

Keywords: ART; Ethiopia; HIV; decentralisation; paediatric; primary health care.

Fig. 1

Retention in care [compared to adverse outcomes death and loss to follow-up (LTFU)] for different patient categories. Subjects are censored after their respective time of treatment and at time of registered transfer out. (a) Patients on antiretroviral therapy (ART patients), with regard to type of health facility. (b) Patients not having started ART (from enrolment to last follow-up or start of ART), with regard to type of health facility. (c) ART patients (from time of ART initiation) compared to pre-ART patients (from time of registration). Patients starting ART during follow-up are excluded from the pre-ART cohort.

Fig. 2

Median weight-for-age z-scores (WAZ) for patients on antiretroviral therapy (ART) during the first 13 months after ART initiation at three defined time points. A total of 31 outliers were excluded at baseline, four after 5–7 months, and one after 11–13 months. TS: p=0.098; 5–7 months: p=0.590; 11–13 months: p=0.466. The numbers of patients included (number of cases with missing WAZ data) are given under the columns. TS, treatment start (date at start of ART).