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Cochrane Database of Systematic Reviews

Decentralising HIV treatment in lower‐ and middle‐income countries

Information

DOI:
https://doi.org/10.1002/14651858.CD009987.pub2Copy DOI
Database:
  1. Cochrane Database of Systematic Reviews
Version published:
  1. 27 June 2013see what's new
Type:
  1. Intervention
Stage:
  1. Review
Cochrane Editorial Group:
  1. Cochrane HIV/AIDS Group

Copyright:
  1. Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

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Authors

  • Tamara Kredo

    Correspondence to: South African Cochrane Centre, South African Medical Research Council, Tygerberg, South Africa

    [email protected]

  • Nathan Ford

    Médecins Sans Frontières, Geneva, Switzerland

  • Folasade B Adeniyi

    Centre for Evidence‐based Health Care, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa

  • Paul Garner

    Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK

Contributions of authors

TK and FBA conducted eligibility of the searches, and together with NF did data extraction, and quality assessment. PG resolved differences when needed. TK entered the data and conducted the analyses and wrote the first draft of the review. NF, FBA and PG provided regular feedback into the overall results and their interpretation. PG developed the framework for the nomenclature and models of health care delivery which were initially described in the protocol.

Sources of support

Internal sources

  • South African Cochrane Centre, South Africa.

External sources

  • World Health Organization, Department of HIV/AIDS, Switzerland.

    Provided some funding support towards completing this review, as a subcontract through the University of California, San Francisco (UCSF)

  • UKaid from the UK Government for the benefit of developing countries (DFiD), UK.

    Funding received through a grant from DFiD to the Effective Health Care Research Consortium

Declarations of interest

None declared.

Acknowledgements

The Effective Health Care Research Consortium, including Paul Garner, are funded by UKaid from the UK Government for the benefit of developing countries. We would also like to acknowledge the assistance of the South African Cochrane Centre. Thanks for the support from the Cochrane HIV/AIDS Review Group, University of California, San Francisco.

Version history

Published

Title

Stage

Authors

Version

2013 Jun 27

Decentralising HIV treatment in lower‐ and middle‐income countries

Review

Tamara Kredo, Nathan Ford, Folasade B Adeniyi, Paul Garner

https://doi.org/10.1002/14651858.CD009987.pub2

2012 Jul 11

Decentralising HIV treatment delivery in middle‐ and low‐income countries

Protocol

Tamara Kredo, Nathan Ford, Folasade B Adeniyi, Paul Garner

https://doi.org/10.1002/14651858.CD009987

Differences between protocol and review

Newcastle‐Ottawa tool for assessing quality of cohort studies was not used in the review as it did not adequately address the relevant items of quality included studies.

Keywords

MeSH

Study flow diagram.
Figures and Tables -
Figure 1

Study flow diagram.

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
Figures and Tables -
Figure 2

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

Forest plot of comparison: 1 Partial decentralisation ‐ initiation in hospital, maintenance at health centre, outcome: 1.1 Death or lost to care (12 months).
Figures and Tables -
Figure 3

Forest plot of comparison: 1 Partial decentralisation ‐ initiation in hospital, maintenance at health centre, outcome: 1.1 Death or lost to care (12 months).

Forest plot of comparison: 1 Partial decentralisation ‐ initiation in hospital, maintenance at health centre, outcome: 1.2 Lost to care.
Figures and Tables -
Figure 4

Forest plot of comparison: 1 Partial decentralisation ‐ initiation in hospital, maintenance at health centre, outcome: 1.2 Lost to care.

Forest plot of comparison: 1 Partial decentralisation ‐ initiation in hospital, maintenance at health centre, outcome: 1.3 Death.
Figures and Tables -
Figure 5

Forest plot of comparison: 1 Partial decentralisation ‐ initiation in hospital, maintenance at health centre, outcome: 1.3 Death.

Forest plot of comparison: 2 Full decentralisation ‐ initiation and maintenance in health centre, outcome: 2.1 Death or lost to care (12 months).
Figures and Tables -
Figure 6

Forest plot of comparison: 2 Full decentralisation ‐ initiation and maintenance in health centre, outcome: 2.1 Death or lost to care (12 months).

Forest plot of comparison: 2 Full decentralisation ‐ initiation and maintenance in health centre, outcome: 2.2 Lost to care.
Figures and Tables -
Figure 7

Forest plot of comparison: 2 Full decentralisation ‐ initiation and maintenance in health centre, outcome: 2.2 Lost to care.

Forest plot of comparison: 2 Full decentralisation ‐ initiation and maintenance in health centre, outcome: 2.3 Death.
Figures and Tables -
Figure 8

Forest plot of comparison: 2 Full decentralisation ‐ initiation and maintenance in health centre, outcome: 2.3 Death.

Forest plot of comparison: 3 Decentralisation ‐ from the facility to the community for antiretroviral maintenance therapy, outcome: 3.1 Death or lost to care (12 months).
Figures and Tables -
Figure 9

Forest plot of comparison: 3 Decentralisation ‐ from the facility to the community for antiretroviral maintenance therapy, outcome: 3.1 Death or lost to care (12 months).

Forest plot of comparison: 3 Decentralisation ‐ to community from facility, outcome: 3.2 lost to care.
Figures and Tables -
Figure 10

Forest plot of comparison: 3 Decentralisation ‐ to community from facility, outcome: 3.2 lost to care.

Forest plot of comparison: 3 Decentralisation ‐ to community from facility, outcome: 3.1 Death.
Figures and Tables -
Figure 11

Forest plot of comparison: 3 Decentralisation ‐ to community from facility, outcome: 3.1 Death.

Comparison 1 Partial decentralisation ‐ initiation in hospital, maintenance at health centre, Outcome 1 Death or lost to care (12 months).
Figures and Tables -
Analysis 1.1

Comparison 1 Partial decentralisation ‐ initiation in hospital, maintenance at health centre, Outcome 1 Death or lost to care (12 months).

Comparison 1 Partial decentralisation ‐ initiation in hospital, maintenance at health centre, Outcome 2 Lost to care.
Figures and Tables -
Analysis 1.2

Comparison 1 Partial decentralisation ‐ initiation in hospital, maintenance at health centre, Outcome 2 Lost to care.

Comparison 1 Partial decentralisation ‐ initiation in hospital, maintenance at health centre, Outcome 3 Death.
Figures and Tables -
Analysis 1.3

Comparison 1 Partial decentralisation ‐ initiation in hospital, maintenance at health centre, Outcome 3 Death.

Study

Down referred patient

Hospital care patient

P‐value

cost of travel

Humphreys 2010

Average cost for follow up care USD 0.74

Average cost for follow up care USD 1.5

P = 0.001

Figures and Tables -
Analysis 1.4

Comparison 1 Partial decentralisation ‐ initiation in hospital, maintenance at health centre, Outcome 4 Cost of travel.

Comparison 2 Full decentralisation ‐ initiation and maintenance in health centre, Outcome 1 Death or lost to care (12 months).
Figures and Tables -
Analysis 2.1

Comparison 2 Full decentralisation ‐ initiation and maintenance in health centre, Outcome 1 Death or lost to care (12 months).

Comparison 2 Full decentralisation ‐ initiation and maintenance in health centre, Outcome 2 Lost to care.
Figures and Tables -
Analysis 2.2

Comparison 2 Full decentralisation ‐ initiation and maintenance in health centre, Outcome 2 Lost to care.

Comparison 2 Full decentralisation ‐ initiation and maintenance in health centre, Outcome 3 Death.
Figures and Tables -
Analysis 2.3

Comparison 2 Full decentralisation ‐ initiation and maintenance in health centre, Outcome 3 Death.

Comparison 3 Decentralisation ‐ from the facility to the community for antiretroviral maintenance therapy, Outcome 1 Death or lost to care (12 months).
Figures and Tables -
Analysis 3.1

Comparison 3 Decentralisation ‐ from the facility to the community for antiretroviral maintenance therapy, Outcome 1 Death or lost to care (12 months).

Comparison 3 Decentralisation ‐ from the facility to the community for antiretroviral maintenance therapy, Outcome 2 Lost to care.
Figures and Tables -
Analysis 3.2

Comparison 3 Decentralisation ‐ from the facility to the community for antiretroviral maintenance therapy, Outcome 2 Lost to care.

Comparison 3 Decentralisation ‐ from the facility to the community for antiretroviral maintenance therapy, Outcome 3 Death.
Figures and Tables -
Analysis 3.3

Comparison 3 Decentralisation ‐ from the facility to the community for antiretroviral maintenance therapy, Outcome 3 Death.

Study

Home based care

Hospital based care

Jaffar 2009

total cost per year for transport, lunch, childcare costs, lost work time: $18/year (after first year)

total cost per year for transport, lunch, childcare costs, lost work time: $54/ year (after the first year)

Kipp 2010

Transport cost $0.74/ visit for home based care

Transport cost $1.5/ visit for facility based care

Figures and Tables -
Analysis 3.4

Comparison 3 Decentralisation ‐ from the facility to the community for antiretroviral maintenance therapy, Outcome 4 Cost to patient.

Summary of findings for the main comparison. Antiretroviral therapy initiated in a hospital, maintained at a health centre for HIV infected patients

Antiretroviral therapy initiated in a hospital, maintained at a health centre for HIV infected patients

Patient or population: HIV infected patients
Settings: Lower‐ and middle‐income countries
Intervention: Antiretroviral therapy initiated in a hospital, maintained at a health centre

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

No of Participants
(studies)

Quality of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

Control

Antiretroviral therapy initiated in a hospital, maintained at a health centre

Death or lost to care
Follow‐up: 12 months

218 per 1000

100 per 1000
(63 to 155)

RR 0.46
(0.29 to 0.71)

39090
(4 studies)

⊕⊕⊕⊝
moderate1,2,3

Lost to care
Follow‐up: 12 months4

134 per 1000

74 per 1000
(60 to 93)

RR 0.55
(0.45 to 0.69)

39090
(4 studies)

⊕⊕⊝⊝
low2,5

Death
Follow‐up: 12 months6

84 per 1000

28 per 1000
(11 to 73)

RR 0.34
(0.13 to 0.87)

39090
(4 studies)

⊕⊕⊝⊝
low2,7,8,9

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: Confidence interval; RR: Risk ratio;

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

1 No serious inconsistency. All four studies report a decrease in attrition at 12 months.
2 Not downgraded for indirectness. The studies included adults (two studies), children (1 study) or both (1 study); and were conducted in sub‐Saharan Africa (South Africa, Malawi).
3 Upgraded by 1 for large effect size. The effect estimate indicated a 54% decrease in attrition in the decentralised group.
4 Adjusted rates for Brennan 2011, Chan 2010 and Fatti 2010 are consistent with the crude proportions reported here. In Brennan 2011, the adjusted hazard ratio was 0.3 (95% CI 0.2 to 0.6)/ 100 person years indicating better outcomes at the health centre. Chan 2010 reported an adjusted odds ratio of 0.48 (95% CI 0.4 to 0.58) indicating better outcomes at the health centre. Fatti 2010 presented the results inversing the site of risk, the adjusted hazard ratio was 2.19 (1.94 to 2.24) indicating greater problems with patients failing to attend the hospital.
5 No serious inconsistency. Three of the four studies show benefit with varied effect sizes (39%. 51% and 66% reduction in patients lost to care), the smallest study reports no difference in clinic follow‐up at 12 months.
6 Adjusted rates for Brennan 2011, Chan 2010 and Fatti 2010 are consistent with the crude proportions reported here. In Brennan 2011, the adjusted hazard ratio was 0.2 (95% CI 0.04 to 0.8)/ 100 person years indicating better outcomes at the health centre. Chan 2010 reported an adjusted odds ratio of 0.19 (95% CI 0.15 to 0.25) indicating better outcomes at the health centre. Fatti 2010 presented the results inversing the site of risk, the adjusted hazard ratio was 1.6 (95% CI 1.3 to 1.99) indicating relatively increased risk of death in patients attending the hospital.
7 Not downgraded for methodological limitations. For one included study (Fatti 2010), the health centre group had balanced CD4 cell counts, but more severe illness ‐ 79% had WHO clinical stage III or IV disease compared with 58% in the hospital group. However, this would tend to favour the hospital group so we did not downgrade on baseline imbalance.
8 No serious inconsistency. All four studies show decrease in death at 12 months with varied effect sizes (10%, 74%, 77% and 81% reductions).
9 Not upgraded for large effect size, despite large effect size and narrow confidence interval, this review is not aiming to explore whether decentralisation decreases death, rather excluding that it increases death. The model of care down refers healthier patients for maintenance therapy, generally sicker patients remain at the hospital setting, this therefore favours decentralisation.

Figures and Tables -
Summary of findings for the main comparison. Antiretroviral therapy initiated in a hospital, maintained at a health centre for HIV infected patients
Summary of findings 2. Antiretroviral therapy started and maintained in a health centre for HIV infected patients

Antiretroviral therapy be started and maintained in health centre for HIV infected patients

Patient or population: HIV infected patients
Settings: Lower‐ and middle‐income countries
Intervention: Antiretroviral therapy be started and maintained in health centre

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

No of Participants
(studies)

Quality of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

Control

Antiretroviral therapy be started and maintained in health centre

Death or lost to care
Follow‐up: 12 months

365 per 1000

256 per 1000
(172 to 373)

RR 0.7
(0.47 to 1.02)

56360
(4 studies)

⊕⊝⊝⊝
very low1,2,3,4

Lost to care
Follow‐up: 12 months

270 per 1000

81 per 1000
(46 to 146)

RR 0.3
(0.17 to 0.54)

56360
(4 studies)

⊕⊕⊕⊝
moderate3,5,6,7

Death
Follow‐up: 12 months

97 per 1000

106 per 1000
(61 to 185)

RR 1.1
(0.63 to 1.92)

55099
(4 studies)

⊕⊝⊝⊝
very low1,3,8,9

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: Confidence interval; RR: Risk ratio;

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

1 Downgraded by 1 for methodological limitations. Bedelu 2008, McGuire 2013 and Massaquoi 2009 included sicker patients at the hospital setting, Assefa has unknown baseline risk as other baseline characteristics were not reported. This bias would tend to favour therapy provided at the health centre.
2 Not downgraded for inconsistency. Three studies report significantly reduced attrition with decentralisation (13%, 42% and 52%), while one study reported no difference.
3 Not downgraded for indirectness. The studies included adults (3 studies) or adults and children (1 study); and were conducted in sub‐Saharan Africa (South Africa, Malawi and Ethiopia). This model of care is probably applicable in better resourced settings where basic levels of healthcare are likely to be better resourced, favouring decentralisation.
4 Downgraded by 1 for imprecision. Although the sample sizes are large and event rates are high, the confidence interval is wide including both appreciable benefit and the null effect.
5 Not downgraded for risk of bias. Four retrospective cohorts provided data. Although there were differences in their baseline health status (Bedelu 2008, Massaquoi 2009 and McGuire 2012 included sicker patients at the hospital), this study limitation is not expected to impact on the attendance at the clinic.
6 Not downgraded for inconsistency. All four studies showed substantially better clinic attendance with decentralisation, however, the effect sizes varied, 24%, 63%, 80% and 89% reductions.
7 Upgraded by 1 for large effect size . The effect size indicates a 70% lower rate of failure to attend clinic follow‐up at the health centre compared to hospital.
8 Downgraded for inconsistency.There is qualitative heterogeneity, Bedelu 2008, Massaquoi 2009 and McGuire 2013 include sicker patients at the hospital, yet only McGuire showed increased death in that setting. Therefore the inconsistency is unexplained.
9 Downgraded by 1 for imprecision. Although the sample sizes are large and event rates are high, the confidence interval is wide including both appreciable benefit and harm.

Figures and Tables -
Summary of findings 2. Antiretroviral therapy started and maintained in a health centre for HIV infected patients
Summary of findings 3. Decentralisation from the facility to the community for antiretroviral maintenance therapy for HIV‐infected patients on antiretroviral therapy

Decentralisation from the facility to the community for antiretroviral maintenance therapy for HIV‐infected patients

Patient or population: HIV‐infected patients
Settings: Lower‐ and middle‐income countries
Intervention: Decentralisation from the facility to the community for antiretroviral maintenance therapy

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

No of Participants
(studies)

Quality of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

Control

Decentralisation from the facility to the community for antiretroviral maintenance therapy

Death or lost to care
Follow‐up: 12 months

106 per 1000

101 per 1000
(66 to 155)

RR 0.95
(0.62 to 1.46)

709
(2 studies)

⊕⊕⊕⊝
moderate1,2

Lost to care
Follow‐up: 12 months3

26 per 1000

21 per 1000
(8 to 57)

RR 0.81
(0.3 to 2.21)

709
(2 studies)

⊕⊕⊕⊝
moderate1,2

Death
Follow‐up: 12 months4

Moderate

RR 1.03
(0.64 to 1.65)

709
(2 studies)

⊕⊕⊕⊝
moderate1,2

55 per 1000

57 per 1000
(35 to 91)

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: Confidence interval; RR: Risk ratio;

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

1 Not downgraded for indirectness. Note that the trials were conducted in Kenya and Uganda in adult populations.
2 Downgraded by 1 for imprecision. These two cluster trials have been pooled after adjusting for the design effect. The intra‐cluster co‐efficient was assumed, as it was not provided in the trial reports.The included studies have small sample sizes and wide confidence intervals which include appreciable harm and benefit.
3 The cluster randomised controlled trials Selke 2010 and Jaffar 2009 are included in this pooled analysis. Selke 2010 reports the adjusted incidence rate ratio for patients lost to care as IRR 1.15 (95% CI 0.24 to 3.03), P = 1.0
4 The cluster randomised controlled trials Selke 2010 and Jaffar 2009 are included in this pooled analysis. Jaffar 2009 reports the adjusted rate ratio for death, RR 0.95(95% CI 0.71 to 1.28); Selke 2010 did not provide adjusted rates for this outcome.

Figures and Tables -
Summary of findings 3. Decentralisation from the facility to the community for antiretroviral maintenance therapy for HIV‐infected patients on antiretroviral therapy
Table 1. Health service nomenclature in lower‐ and middle‐income countries

Tier

Highest cadre

Terms often used

Facility and staff

Equipment facilities

Community

Individual with maximum of few months training; paid or unpaid

1a. Family led care

Family member

 

 

1b. Village volunteer

Trained volunteer; health assistants

HIV tests, counselling,  replenish drugs

 

1c. Primary care clinic

Nurse aide or community health worker with a few months training

 

Health centre

clinical officer or nurse (2+ years training)

Health centres; district hospitals

Purpose built with at least one paramedic or nurse with some health assistants

HIV tests; antiretrovirals; opportunistic infections medicines; point of care laboratories

Health centre (enhanced)

Clinical officer or nurse (2 + years training)

Health centres, primary healthcare clinics, district hospitals

Purpose built with at least one paramedic or nurse with some health assistants, with input from a doctor (may be via mobile support service)

HIV tests; antiretrovirals; opportunistic infections medicines; point of care laboratories

Hospital

Doctor

Health centres; district hospitals

Purpose built with at least one medical doctor with nurses / paramedics and assistants

CD4 count

Medicines

Not viral load

Hospital (advanced)

Specialist doctor

District hospital; referral hospital

Purpose built with at least 2 specialist doctors with nurses / paramedics and assistants

Viral load and full investigations

Figures and Tables -
Table 1. Health service nomenclature in lower‐ and middle‐income countries
Table 2. Models of HIV care

Our term

Initiation

Follow‐up

Standard hospital model

Hospital

Hospital

Partial decentralisation

Hospital

Health centre

Full decentralisation

Health centre

Health centre

Full decentralisation with regular hospital support

Health centre (weekly clinics with hospital staff)

Health centre (weekly clinics with hospital staff)

Community

Primary (tier 1c)

Health centre

 

Primary (tier 1c)

(monitor six monthly by health centre)

Figures and Tables -
Table 2. Models of HIV care
Table 3. Description of the models of care of included studies

Models of care 

Provider details

Laboratory facilities

Community support

Training in ART initiation and maintenance

Supervision or mentoring

Referral

Partial decentralisation

Bock 2008

Health centres (enhanced)

Doctors

yes

not stated

not stated

specialists available

yes

Hospital (advanced)

Doctors

yes

not stated

yes

specialists available

not applicable

Brennan 2011

Health centres

Primary health care nurses

not stated

not stated

yes 

yes ‐ telephonic

yes ‐ to hospital

 

Hospitals

Doctors

not stated

not stated

not applicable

not applicable

not applicable

Chan 2010

Health centres

Nurses and health surveillance assistants

no 

Expert patients

yes 

yes ‐ from hospital

not stated

 

Hospitals

Clinical officers, nurses and doctors

yes

Home‐based care volunteers

not applicable

not applicable

not stated

Fatti 2010

Health centres

Doctors

yes

Community‐based adherence counsellors

not stated

not stated

not stated

 

Hospitals

Doctors

yes

not stated

not stated

not stated

not stated

Hansudewechakul 2012

health centres

Nurses

yes

yes

yes

yes

not stated

Hospital

Doctors

yes

yes

yes

not applicable

not stated

Humphreys 2010

Health centres

Nurses

no

not stated

yes

yes ‐ monthly visit from nurse and counsellor

yes

Hospital

Doctors

yes

not stated

not applicable

not applicable

not applicable

Full decentralisation

Assefa 2012

Health centres

Health officers, nurse

not stated

Community health workers, adherence counselling, defaulter tracing, referral and linkage between facilities

not stated

not stated

yes ‐ to hospital

 

Hospitals

Doctors

not stated

none 

not stated

not stated

not applicable

Balcha 2010

Health centres

Health officers, nurses, data clerk, pharmacy technicians

not stated

not stated

not stated

not stated

yes ‐ to hospital

 

Hospitals

Nurses, data clerks, pharmacists

not stated

not stated

not stated

not stated

not applicable

Bedelu 2007

Health centres

Nurses 

no

Community health workers, adherence support, defaulter tracing

yes 

yes ‐ mobile team

yes ‐ to hospital

 

Hospitals

Doctors

yes

no

not stated

not applicable

not applicable

Fayorsey 2013

health centres

doctors and nurses

8/182 sites CD4 machines

variable by site

not stated

not stated

yes

Hospitals

doctors and nurses

54/92 sites Cd4 machines

variable by site

not stated

not stated

not applicable

Massaquoi 2009

Health centres

Medical assistants and nurse

yes

yes

yes 

yes

yes ‐ to hospital

 

Hospitals

Doctors

yes

not stated

yes 

not applicable

not applicable

McGuire 2012

Health centres

Clinical officers, nurses and medical assistants

yes

yes

yes

not stated

yes

Hospitals

Clinical officers and nurses

yes

yes

not stated

not stated

not applicable

Odafe 2012

Hospitals

Medical doctors

yes

yes

not stated

not stated

not stated

Hospitals (advanced)

Medical specialists

yes

not stated

not stated

not applicable

not applicable

Decentralisation from facility to community 

Jaffar

Community

Field officers

no

not stated

yes 

yes

yes 

 

Health centres

Clinical staff

yes

not stated

yes 

yes

not applicable

Kipp

Community

Unpaid volunteers, >18 years old and literate

 no

Treatment supporter to assist with adherence

yes

 yes

 yes

 

Health centres

Doctors

 yes

 no

 not applicable

 not stated

not applicable 

Selke

Community

Community care co‐ordinators

no

Computer aided devices

yes 

yes

yes

 

Health centres

Clinical officers, doctor (1 day/ week)

yes

no

not applicable

not applicable

not applicable

Figures and Tables -
Table 3. Description of the models of care of included studies
Comparison 1. Partial decentralisation ‐ initiation in hospital, maintenance at health centre

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Death or lost to care (12 months) Show forest plot

4

39090

Risk Ratio (IV, Random, 95% CI)

0.46 [0.29, 0.71]

1.1 Adults

2

29492

Risk Ratio (IV, Random, 95% CI)

0.49 [0.21, 1.12]

1.2 Children

1

1505

Risk Ratio (IV, Random, 95% CI)

0.45 [0.27, 0.74]

1.3 Adults and children

1

8093

Risk Ratio (IV, Random, 95% CI)

0.39 [0.35, 0.43]

2 Lost to care Show forest plot

6

Risk Ratio (IV, Random, 95% CI)

Subtotals only

2.1 Lost to care (6 months)

3

28699

Risk Ratio (IV, Random, 95% CI)

0.99 [0.56, 1.76]

2.2 Lost to care (12 months)

4

39090

Risk Ratio (IV, Random, 95% CI)

0.55 [0.45, 0.69]

2.3 Lost to care (24 months)

1

543

Risk Ratio (IV, Random, 95% CI)

0.0 [0.0, 0.0]

3 Death Show forest plot

6

Risk Ratio (IV, Random, 95% CI)

Subtotals only

3.1 Death (6 months)

3

28699

Risk Ratio (IV, Random, 95% CI)

0.52 [0.19, 1.41]

3.2 Death (12 months)

4

39090

Risk Ratio (IV, Random, 95% CI)

0.34 [0.13, 0.87]

3.3 Death (24 months)

1

543

Risk Ratio (IV, Random, 95% CI)

0.04 [0.00, 0.58]

4 Cost of travel Show forest plot

Other data

No numeric data

4.1 cost of travel

Other data

No numeric data

Figures and Tables -
Comparison 1. Partial decentralisation ‐ initiation in hospital, maintenance at health centre
Comparison 2. Full decentralisation ‐ initiation and maintenance in health centre

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Death or lost to care (12 months) Show forest plot

4

56360

Risk Ratio (IV, Random, 95% CI)

0.70 [0.47, 1.02]

1.1 Adults

3

52286

Risk Ratio (IV, Random, 95% CI)

0.62 [0.39, 0.99]

1.2 Adults and children

1

4074

Risk Ratio (IV, Random, 95% CI)

0.97 [0.82, 1.15]

2 Lost to care Show forest plot

6

Risk Ratio (IV, Random, 95% CI)

Subtotals only

2.1 Lost to care (6 months)

2

51261

Risk Ratio (IV, Random, 95% CI)

0.53 [0.26, 1.10]

2.2 Lost to care (12 months)

4

56360

Risk Ratio (IV, Random, 95% CI)

0.30 [0.17, 0.54]

2.3 Lost to care (24 months)

4

61445

Risk Ratio (IV, Random, 95% CI)

0.50 [0.36, 0.71]

3 Death Show forest plot

6

Risk Ratio (IV, Random, 95% CI)

Subtotals only

3.1 Death (6 months)

2

50000

Risk Ratio (IV, Random, 95% CI)

0.84 [0.35, 2.00]

3.2 Death (12 Months)

4

55099

Risk Ratio (IV, Random, 95% CI)

1.10 [0.63, 1.92]

3.3 Death (24 months)

4

60184

Risk Ratio (IV, Random, 95% CI)

0.64 [0.39, 1.06]

Figures and Tables -
Comparison 2. Full decentralisation ‐ initiation and maintenance in health centre
Comparison 3. Decentralisation ‐ from the facility to the community for antiretroviral maintenance therapy

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Death or lost to care (12 months) Show forest plot

2

709

Risk Ratio (IV, Random, 95% CI)

0.95 [0.62, 1.46]

2 Lost to care Show forest plot

3

Risk Ratio (IV, Random, 95% CI)

Subtotals only

2.1 Lost to care (6 months)

1

385

Risk Ratio (IV, Random, 95% CI)

1.49 [0.81, 2.74]

2.2 Lost to care (12 months)

2

709

Risk Ratio (IV, Random, 95% CI)

0.81 [0.30, 2.21]

2.3 Lost to care (24 months)

1

385

Risk Ratio (IV, Random, 95% CI)

0.74 [0.46, 1.20]

3 Death Show forest plot

3

Risk Ratio (IV, Random, 95% CI)

Subtotals only

3.1 Death (6 months)

1

385

Risk Ratio (IV, Random, 95% CI)

1.44 [0.81, 2.57]

3.2 Death (12 months)

2

709

Risk Ratio (IV, Random, 95% CI)

1.03 [0.64, 1.65]

3.3 Death (24 months)

1

385

Risk Ratio (IV, Random, 95% CI)

1.50 [0.91, 2.47]

4 Cost to patient Show forest plot

Other data

No numeric data

Figures and Tables -
Comparison 3. Decentralisation ‐ from the facility to the community for antiretroviral maintenance therapy