Intervention Review

You have free access to this content

Decentralising HIV treatment in lower- and middle-income countries

  1. Tamara Kredo1,*,
  2. Nathan Ford2,
  3. Folasade B Adeniyi3,
  4. Paul Garner4

Editorial Group: Cochrane HIV/AIDS Group

Published Online: 27 JUN 2013

Assessed as up-to-date: 26 MAY 2013

DOI: 10.1002/14651858.CD009987.pub2


How to Cite

Kredo T, Ford N, Adeniyi FB, Garner P. Decentralising HIV treatment in lower- and middle-income countries. Cochrane Database of Systematic Reviews 2013, Issue 6. Art. No.: CD009987. DOI: 10.1002/14651858.CD009987.pub2.

Author Information

  1. 1

    South African Medical Research Council, South African Cochrane Centre, Tygerberg, Western Cape, South Africa

  2. 2

    Médecins Sans Frontières, Geneva, Switzerland

  3. 3

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

  4. 4

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

*Tamara Kredo, South African Cochrane Centre, South African Medical Research Council, PO Box 19070, Tygerberg, Western Cape, 7505, South Africa. tamara.kredo@mrc.ac.za.

Publication History

  1. Publication Status: New
  2. Published Online: 27 JUN 2013

SEARCH

 
Characteristics of included studies [ordered by study ID]
Assefa 2012

MethodsDesign: Retrospective cohort

Duration of study: Recruitment Sept 2006-2008, censored March 2009 (minimum 6 months, maximum 24 months follow-up)


ParticipantsCountry: Ethiopia

Setting: Nationwide, 30 hospitals, 25 health centres

Inclusion and exclusion criteria: None described

Comparable CD4 count or clinical stage at baseline: Similar CD4 count


InterventionsIntervention: Patients initiated and maintained at health centres by nurses and health officers. Severe manifestations, treatment failures were referred to hospital

Control: Initiated and followed up at hospital with physicians.

Co-interventions: Community health workers performed counselling, referrals and linkage between facilities and defaulter tracing, not clear if this was provided at all sites


OutcomesMortality, loss to follow-up, retention, and median CD4+ cell count,

Assessed at 6, 12 and 24 months


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Baseline CD4 count (All studies)Low riskSimilar median CD4 counts at baseline in both groups

Other baseline variables (All studies)Unclear riskNot described

Co-interventions (All studies)Unclear riskCommunity health workers delivered adherence and referral services from health centres to hospitals, unclear whether this was for both groups for the health centre group only

Data collection (Cohorts)High riskRetrospective cohort

Patient selection bias (Cohorts)Low riskRandomly selected folders in all included sites in both groups

Balcha 2010

MethodsDesign: Retrospective cohort

Duration: February 2007 - February 2009, 6 months post censor follow-up


ParticipantsCountry: Ethiopia

Setting: Rural and urban, in one region, 3 health centres, 2 hospitals

Inclusion criteria: Adults eligible for antiretroviral treatment (CD4 <200cell/mm3 or WHO clinical stage 3 or 4) and on treatment for < 6 months

Exclusion: HIV infected, but not on antiretroviral therapy

Comparable CD4 count or clinical stage at baseline: Similar CD4 count


InterventionsIntervention: Initiation on antiretrovirals in health centre, maintenance in health centre; provided by nurses and health officers

Control: Initiated and maintained in hospital, provided by doctors

Co-interventions: None described


OutcomesCurrently alive and on treatment, loss to follow-up, transferred out, mortality

Assessed at 24 months


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Baseline CD4 count (All studies)Low riskSimilar median CD4 in both groups

Other baseline variables (All studies)Unclear riskOnly data on sex reported by arm

Co-interventions (All studies)Unclear riskNo co-intervention information described

Data collection (Cohorts)High riskRetrospective cohort

Patient selection bias (Cohorts)Low riskNo selection bias identified

Bedelu 2007

MethodsDesign: Retrospective cohort

Duration: January 2004 - June 2005, completed 12 months follow-up by July 2006


ParticipantsCountry: South Africa

Setting: Rural, 12 health centres, 1 hospital

Inclusion criteria: Adults, eligible for ART CD4+ cell count < 200cells/mm3, WHO clinical stage 4

Exclusion criteria: None described

Comparable CD4+ cell count or clinical stage at baseline: CD4+ cell counts differed at baseline (sicker at hospital)


InterventionsIntervention: ART initiated and maintained at health centre by nurses, physician support with mobile team, adherence counsellors and patient support groups available

Control: ART initiated and maintained at hospital by doctors


OutcomesMortality, loss to follow-up, CD4 count, viral load

Assessed at 12 months


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Baseline CD4 count (All studies)High riskCD4+ cell counts differed between groups at baseline, lower CD4+ cell counts remained at the hospital

Other baseline variables (All studies)Unclear riskOnly reported on sex of included participants

Co-interventions (All studies)High riskModel differed by group: The health centre group received additional adherence support and visits from a mobile support team of experienced clinicians

Data collection (Cohorts)High riskRetrospective cohort

Patient selection bias (Cohorts)Low riskNo selection bias identified

Bock 2008

MethodsDesign: Retrospective cohort

Duration: April 2004 - April 2006, no follow-up post censor described


ParticipantsCountry: South Africa

Setting: Urban, peri-urban, 20 health centres (enhanced), 16 hospitals, 3 advanced hospitals

Inclusion criteria: Children <15 years, eligible for ART (modified WHO stage 2, 3 disease, or low CD4% by age group - <20% if <18 months old, or <15% if >18 months old), recurrent hospitalisation >4 weeks, and identifiable caregiver

Exclusion criteria: Previous exposure to ART for >1 month (treatment experienced), transferred in or out of antiretroviral treatment site

Comparable CD4+ cell count or clinical stage at baseline: Sicker children with lower CD4 % at hospital and advanced hospital


InterventionsIntervention (Primary health care clinics): ART initiated at advanced hospital, maintained at enhanced health centres, by doctors

Intervention (Level 1 district hospitals): ART initiated at advanced hospital, maintained at hospital, by doctors

Control (level 2 and 3 facilities): ART initiated and maintained at advanced hospital, by doctors and specialists


OutcomesDeath, loss to follow-up, virological suppression, CD4 % changes, change to second line treatment

Assessed at 6, 12 and 18 months


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Baseline CD4 count (All studies)High riskSicker children with lower CD4 % at hospital and advanced disease remained in hospital

Other baseline variables (All studies)Unclear riskNot described

Co-interventions (All studies)Unclear riskNot described

Data collection (Cohorts)High riskRetrospective cohort

Patient selection bias (Cohorts)Low riskAlthough stable patients could be transferred to the PHC group while sicker children requiring specialist care were transferred to advanced hospital, this group of patients were excluded from the analysis.

Brennan 2011

MethodsDesign: Retrospective matched cohort analysis

Duration: April 2004 - January 2009


ParticipantsCountry: South Africa

Setting: Peri-urban, urban, 1 hospital, 1 clinic

Inclusion criteria: Stable on antiretroviral treatment for at least 11 months, no opportunistic infections, CD4+ cell count > 200cells/mm3, stable weight and virologically suppressed <400 copies/mL. Considered good candidates by doctors and agree to down-referral

Exclusion criteria: Refused down referral

Comparable CD4 count or clinical stage at baseline: Control matched on sex, age, months on therapy, treatment regimen, BMI, HB and CD4+ cell count (propensity scoring)


InterventionsIntervention: ART initiated at advanced hospital by doctors, maintained at health centre by nurses, seen every 2 months for medicine pick up. "Up referred" if default (>7 days), toxicity, detectable viral load

Control: ART initiated and maintained by doctor at advanced hospital, seen 6 monthly, pick up medicines every 2 months

Co-interventions: Adherence counselling provided at both facilities


OutcomesDeath, loss to follow-up, mean CD4+ cell count, viral load rebound

Assessed at 12 months


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Baseline CD4 count (All studies)Low riskMatched by propensity scores on all baseline characteristics

Other baseline variables (All studies)Low riskMatched by propensity scores on all baseline characteristics

Co-interventions (All studies)Low riskBoth groups received adherence counselling

Data collection (Cohorts)High riskRetrospective cohort

Patient selection bias (Cohorts)Low riskAll participants were equally eligible for down referral, and were matched using propensity scores on baseline characteristics

Chan 2010

MethodsDesign: Retrospective cohort

Duration: October 2004 - 31 December 2008, censored 31 December 2008, maximum follow-up 50 months


ParticipantsCountry: Malawi

Setting: Rural, Zomba district, 16 health centres and 1 hospital

Inclusion criteria: Adults and older children eligible for antiretroviral therapy (CD4+ cell count <250 cells/mm3, WHO clinical stage 3 or 4), on treatment for >3 months and stable, no evidence of opportunistic infections or drug intolerance, provider confidence in patient adherence, live closer to health centre than hospital

Exclusion criteria: None described

Comparable CD4+ cell count or clinical stage at baseline: Earlier stage disease at intervention site, more men, children and advanced disease at control site


InterventionsIntervention: ART initiated at advanced hospital, maintained at health centre, seen by nurses and clinical officers, home-based peer support and health surveillance assistants for defaulter tracing, expert patients, nutrition counsellors, volunteers from the community

Control: ART initiated and maintained at hospital, by clinical officers, adherence counsellor and specialist support

Co-intervention: Paediatric and adult specialist support at both sites


OutcomesDeath, loss to follow-up (not seen at facility for >3m)

Unknown time of outcome reporting


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Baseline CD4 count (All studies)Unclear riskNot reported

Other baseline variables (All studies)High riskHealthier at peripheral site: Earlier WHO stage, more women and adults, differing baseline characteristics.

Co-interventions (All studies)High riskPaediatric and adult specialist infectious diseases support at both sites, via mobile visits for health centres. In addition, the intervention group had many antiretroviral therapy counsellors health surveillance assistants, peer home based care providers and community volunteers to support adherence.

Data collection (Cohorts)High riskRetrospective cohort

Patient selection bias (Cohorts)High riskOnly stable patients, on treatment for > 3 months with no opportunistic infections or signs of adverse effects of the medication were decentralised to intervention arm.

Fatti 2010

MethodsDesign: Retrospective cohort

Duration: December 2004 - December 2007, followed up until March 2008


ParticipantsCountry: South Africa

Setting: Four provinces, peri-urban and rural, 47 health centres (enhanced), 9 hospitals and 3 advanced hospitals

Inclusion criteria: Adults >16 years with CD4+ cell count <200cells/mm3 or WHO clinical stage 4, documented date of birth, gender and date of starting antiretroviral therapy

Exclusion criteria: Missing demographic data, antiretroviral therapy experienced, starting antiretroviral therapy after 31 December 2007

Comparable CD4 cell count or clinical stage at baseline: CD4+ cell count clinically similar at baseline (median range 109-113 cells/mm3), but more advanced disease (WHO clinical stage 3 or 4) at primary care facilities


InterventionsIntervention: ART initiated at hospital by doctor and maintained at health centre (enhanced) by doctors

Control: ART initiated and maintained at hospital by doctors

Co-interventions: Adherence counselling by community support workers


OutcomesDeath. loss to follow-up, virological suppression

reported at 12, 24 and 36 months


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Baseline CD4 count (All studies)Low riskSimilar CD4+ cell counts between groups

Other baseline variables (All studies)High riskHealth centres had patients with more advanced disease by WHO clinical stage (note bias in favour of control)

Co-interventions (All studies)Low riskAdherence support provided by community-based adherence counsellor, linking with losses and detecting deaths

Data collection (Cohorts)High riskRetrospective cohort

Patient selection bias (Cohorts)Low riskNo evidence of patient selection bias

Fayorsey 2013

MethodsDesign: Retrospective cohort

Duration:January 2008 to March 2010


ParticipantsCountry: Kenya. Lesotho, Mozambique, Rwanda and Tanzania

Setting: 274 sites, all receiving funding from the Presidents Emergency Plan for AIDS Relief

Inclusion criteria: Children < 15 years old

Exclusion criteria: if initiated on therapy before study period or at another facility they were excluded from analysis

Comparable CD4 cell count or clinical stage at baseline: no data on CD4 counts at baseline or other health related variables


InterventionsIntervention: ART initiated and maintained at health centres by doctor or nurse (43%)

Control: ART initiated and maintained at hospital by doctors or nurse (42%)

Co-interventions:differed by country and site and included nutrition support, outreach services, support groups, PEER educator programme and adherence counselling.


OutcomesLoss to follow-up (not having made a clinic visit or pharmacy pick up in 90 days); mortality (documented death in clinic records)


NotesPrimary health facilities (health centres in our model) included health centres and clinics, secondary health facilities (hospitals) included district, sub-district and provincial hospitals


Risk of bias

BiasAuthors' judgementSupport for judgement

Baseline CD4 count (All studies)Unclear riskNot stated

Other baseline variables (All studies)Unclear riskNone provided

Co-interventions (All studies)High riskVariable by country and setting, therefore not known

Data collection (Cohorts)High riskRetrospective cohort

Patient selection bias (Cohorts)Low riskNo evidence of selection bias

Hansudewechakul 2012

MethodsDesign: Retrospective cohort

Duration: February 2002 to April 2008


ParticipantsCountry: Thailand

Setting: Community-based paediatric HIV care and treatment network, training and supervision were provided

Inclusion criteria: Children, stable on treatment prior to referral (absence of opportunistic infections and improved weight and CD4%)

Exclusion criteria: ART experienced, follow up < 6 months, opportunistic infections, on protease inhibitor

Comparable CD4 cell count or clinical stage at baseline: Median CD4% and viral load was similar, but more CDC stage C at health centre (25% at hospital and 40% at health centre)


InterventionsIntervention: ART initiated at hospital by doctors and maintained at health centres by nurses, under doctor attendance

Control: ART initiated and maintained at hospital by doctors

Co-interventions: Team included nurses/ counsellors, people living with HIV, pharmacists and physicians, adherence monitoring conducted at both sites. This model included mentoring, emails, phone calls and discussion between health centres and hospital


OutcomesMortality, loss to follow-up, weight for age score, adherence, CD4%, viral load change


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Baseline CD4 count (All studies)Low riskBalanced CD4% at baseline

Other baseline variables (All studies)Low riskBaseline variables balanced.

Co-interventions (All studies)Low riskThere was mentoring and support for health centres health staff maintaining ART, however this is part of the model of care and not expected to bias the results.

Data collection (Cohorts)High riskRetrospective cohort

Patient selection bias (Cohorts)Low riskStable patients were referred to the health centres, however, the analysis excluded patients who were ill with opportunistic infections, or who were on a protease inhibitor, and the baseline characteristics were similar

Humphreys 2010

MethodsDesign: Prospective cohort

Duration: Started recruitment January 2007 - June 2007, followed up until November 2007, minimum 6 months follow-up


ParticipantsCountry: Swaziland

Setting: Rural setting, one district hospital, 30 nurse led health centres

Inclusion criteria: Adults >14 years on antiretroviral therapy for at least 4 weeks, CD4+ cell count >100 cells/mm3

Exclusion criteria: refused to be down referred

Comparable CD4+ cell count or clinical stage at baseline: CD4+ cell count and clinical stage similar at baseline


InterventionsIntervention: ART initiated at hospital by doctor and maintained at health centre by nurses

Control: ART initiated and maintained at hospital by doctors

Co-interventions: Training for primary care centre nurses, monthly outreach support visit by at least one counsellor and nurse


OutcomesClinic attendance, patient experience, loss to follow-up, change in CD4 count, weight, death


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Baseline CD4 count (All studies)Low riskSimilar mean CD4+ cell counts between groups

Other baseline variables (All studies)Low riskAge, sex, and weight were similar at baseline

Co-interventions (All studies)Unclear riskNo additional intervention described, other than mobile support team visits monthly which are part of the model of care

Data collection (Cohorts)Low riskProspective Cohort

Patient selection bias (Cohorts)Low riskAssignment was based on catchment areas (intervention clinics / control clinics)

Jaffar 2009

MethodsDesign: Cluster randomised controlled trial, 22 clusters for each arm, median size 25 - 36, inter-cluster co-efficient 0.2

Duration: February 2005 - December 2006, follow-up until 31 January 2009, median follow-up 27 - 28 months


ParticipantsCountry: Uganda

Setting: Urban, peri-urban and rural, varying distance from the hospital

Inclusion criteria: Adults >18 years old, CD4+ cell count <200cells/mm3, WHO clinical stage 3 or 4

Exclusion criteria: Living >100 km from facility

Comparable CD4+ cell count or clinical stage at baseline: Similar, slightly lower CD4+ cell count for intervention arm


InterventionsIntervention: ART initiated at hospital by doctors, maintained in the community by field officers who delivered treatments every month on motorcycles, monitored adherence, drug toxicity and disease, they referred patients; had access to mobile phones for on-site call to doctor. If patients was absent, followed up. Reviewed at hospital 6 monthly.

Control: ART initiated and maintained at hospital. Monthly clinic visits to collect medicine, reviewed by medical officer 3 monthly, drop in clinic; if defaulted, followed up at home; household vouchers for counselling


OutcomesRate of virological failure, time to detectable viral load >500 copies/mL, time to detectable viral load >500 copies/mL at any visit from 12 months if it was <500 copies/mL at 6 months or increase in 1000 copies/mL between two consecutive tests in those who did not have viral load <500 copies/mL at 6 months, all cause mortality, admission, change to second line antiretrovirals, outpatient attendance, adherence in previous 28 days, cost incurred by health services and patients, patient diagnosed with TB at first admission, proportion of those with CD4+ cell count > 200cells/mm3

Timepoints of outcome assessment not clear


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Baseline CD4 count (All studies)Low riskSimilar at baseline

Other baseline variables (All studies)Low riskComparable baseline characteristics

Co-interventions (All studies)Low riskBoth groups seen monthly, but provider and facility differed by group

Random sequence generation (Trials)Unclear riskNot described

Allocation concealment (Trials)Low riskAllocation cards labelled with stratum number and sealed in advance was drawn from a concealed box in the presence of all stakeholders

Contamination protection (Trials)Low riskNo evidence of contamination

Kipp 2010

MethodsDesign: Prospective cohort

Duration: 6 month results


ParticipantsCountry: Rwimi, Uganda

Setting: intervention in rural setting, control in urban setting

Inclusion criteria: Adults >18 years, eligible for antiretroviral therapy, antiretroviral therapy naive, resident in the sub-county

Exclusion criteria: None described

Comparable CD4 count or clinical stage at baseline: Similar CD4+ cell count at baseline


InterventionsIntervention: ART initiated at the health centre, maintained in community receiving care from volunteer community health workers who did weekly home visits - delivering antiretrovirals monthly, monitoring and supporting adherence, monitoring adverse effects and clinical symptoms

Control: ART initiated and maintained in hospital, by doctors

Co-intervention: an additional treatment support was required by those in the home-based group to support adherence and disclosure


OutcomesMortality, viral load, increase in CD4+ cell count, cost to provider

Assessed at 6 months and 24 months


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Baseline CD4 count (All studies)Low riskSimilar mean CD4+ cell count in both groups

Other baseline variables (All studies)Low riskAge, sex and educational status similar at baseline (although occupations different).,

Co-interventions (All studies)High riskTreatment supporter was required by home-based care group

Data collection (Cohorts)Low riskProspective cohort

Patient selection bias (Cohorts)Low riskNo selection bias identified

Massaquoi 2009

MethodsDesign: Retrospective cohort

Duration: 1 June 2006 - 31 June 2007, censored 31 June 2007


ParticipantsCountry: Thyolo District, Malawi

Setting: Rural, 1 hospital, 9 health centres

Inclusion criteria: HIV infected adults and children, eligible for antiretrovirals, CD4 count <250cells/mm3, WHO clinical stage 3 or 4

Exclusion criteria: None described

Comparable CD4 count or clinical stage at baseline: More men and children and stage 4 disease at hospital, more patients with active tuberculosis at the health centre


InterventionsIntervention: ART initiated and maintained at health centre, by medical assistant, 1 nurse

Control: ART initiated and maintained at hospital by clinical officer, medical assistants, nurses, counsellors

Co-interventions: Both have district mobile support teams


OutcomesAttrition (dead, loss to follow-up, stopped treatment), retention (alive and on treatment, and transferred out)

Assessment of outcomes provided in person-years of follow-up


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Baseline CD4 count (All studies)Unclear riskNot reported

Other baseline variables (All studies)High riskSicker at peripheral site: More men and children, WHO clinical stage 4 disease, and fewer patients with active Tuberculosis at control site

Co-interventions (All studies)Unclear riskThe community-based group received monthly visits from volunteer community support providers, and delivery of their medicines. They were also required to identify a treatment supporter at home, not clear if this applied to both groups

Data collection (Cohorts)High riskRetrospective cohort

Patient selection bias (Cohorts)Low riskNo selection bias identified

McGuire 2012

MethodsDesign: Retrospective cohort

Duration: August 2001 to December 2008, compared by year (e.g. 2001/2002; 2003/2004 etc)


ParticipantsCountry: Malawi

Setting: 10 peripheral health centres, 1 district hospital

Inclusion criteria: HIV infected adults, eligible for antiretrovirals, CD4 count <250cells/mm3, WHO clinical stage 3 or 4

Exclusion criteria: None described

Comparable CD4 count or clinical stage at baseline: CD4+ cell count similar at baseline median IQR 176 cells/mm3 [105 -229] at the health centre and 149 cells/mm3 [74 - 219]; however more clinical stage 1 and 2 at the health centre which may favour the intervention, also more men at the hospital


InterventionsIntervention: ART initiated and maintained at health centre, by clinical officers. Medical assistants and nurses could prescribe after 2007

Control: ART initiated and maintained at hospital by clinical officer, medical assistants, nurses

Co-interventions: Lay community workers, peer counsellors for adherence support, group and individual counselling


OutcomesDeath, loss to follow-up and attrition (death and loss to follow-up) at 12 months


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Baseline CD4 count (All studies)High riskHealthier at peripheral site: CD4+ cell count higher.

Other baseline variables (All studies)High riskHealthier at peripheral site: (clinical stage 1 and 2).

Co-interventions (All studies)Low riskdefault tracing by community health workers, seems to be same for both facilities

Data collection (Cohorts)High riskRetrospective cohort

Patient selection bias (Cohorts)Low riskNo evidence of selection bias

Odafe 2012

MethodsDesign: Retrospective cohort

Duration:Initiated therapy between January and December 2007, follow-up data collected until 2010


ParticipantsCountry: Nigeria

Setting: Secondary (medical officers, nurses, laboratory scientists, pharmacists and community heath officers) and tertiary hospitals (medical specialists) in Nigeria where majority of ART initiation occurs

Inclusion criteria: HIV infected adults and children, eligible for antiretrovirals by Nigeria national recommendations, adapted from WHO recommendations

Exclusion criteria: None described

Comparable CD4 count or clinical stage at baseline: CD4+ cell count not reported, but more patients with clinical stage 3 and 4 at the hospital


InterventionsIntervention: ART initiated and maintained at health centre, by clinical officers. Medical assistants and nurses could prescribe after 2007

Control: ART initiated and maintained at hospital by clinical officer, medical assistants, nurses

Co-interventions: Adehrence counselling and pharmacy counselling received at every visit, at both tiers of health service


OutcomesPrimary outcome was attrition, which includes those stopping treatment,confirmed dead or lost to follow-up at 12 and 24 months. Loss to follow-up was defined as those absent from treatment for 90 days.


NotesAs this comparison included tertiary vs secondary hospitals, this differed from other models in the analysis and is therefore described narratively, not included in analysis.


Risk of bias

BiasAuthors' judgementSupport for judgement

Baseline CD4 count (All studies)Unclear riskNot stated

Other baseline variables (All studies)High riskMore patients with WHO clinical stage 3 disease at the secondary hospital, this is likely to increase bias in favour of control

Co-interventions (All studies)Low riskSame approach to adherence support and counselling in both settings

Data collection (Cohorts)High riskRetrospecrive cohort

Patient selection bias (Cohorts)Low riskNo selection bias identified

Selke 2010

MethodsDesign: Cluster randomised controlled trial. Unit of allocation: sub-location, stratified by distance from road, inter cluster co-efficient not found

Duration: March 2006 - April 2008, minimum 12 months follow-up


ParticipantsCountry: Kenya

Setting: Rural, 24 sub-locations

Inclusion criteria: adults >18 years, clinically stable on antiretroviral therapy for 3 months with no adherence issues, disclosed to household members, live within area, informed consent given

Exclusion criteria: Active WHO clinical stage 3 or 4 condition, pregnant, hospitalisation in previous 3 months, unable to understand informed consent process

Comparable CD4 count or clinical stage at baseline:similar CD4+ cell count and WHO clinical stage


InterventionsIntervention: ART initiated at hospital by clinical officer, maintained in community by person living with HIV/AIDS ("community care coordinators" who had secondary education, were clinically stable, 100% adherent and "considered a good role model"; trained, given mobile computer decision aids, visited patients monthly at home and delivered medicines. Three monthly clinic visits seen by doctor or clinical officer

Control: ART initiated at hospital by clinical officer or doctor (10% of visits), maintained at hospital. Visit clinic monthly, seen by nurse and doctor.

Co-interventions: community coordinators had computer decision aids to trigger referral for clinical or social concerns


OutcomesViral load, CD4+ cell count, number of clinic visits, Karnofsky score, stability of antiretroviral regimen, opportunistic infections, pregnancy, adherence to drugs, loss to follow-up

Assessed at 12 months


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Baseline CD4 count (All studies)Low riskSimilar at baseline

Other baseline variables (All studies)Low riskSimilar baseline characteristics including age, sex and WHO clinical staging.

Co-interventions (All studies)Low riskOther than the intervention (computerised decision aids and home-based support) the groups were treated equally.

Random sequence generation (Trials)Unclear riskNot clearly described

Allocation concealment (Trials)Low riskWell described

Contamination protection (Trials)Low riskUnlikely that control group was exposed to intervention

 
Characteristics of excluded studies [ordered by study ID]

StudyReason for exclusion

Babigumira 2009Decision analysis model using one patient as case study.

Bemelmans 2010Description of program outcomes.

Bolton-Moore 2007No contemporaneous comparison group.

Boyer 2010Cross-sectional survey.

Boyer 2012Cross-sectional survey.

Chu 2010Randomised controlled trial conducted in high income country (United States of America).

Cohen 2009No contemporaneous comparison group.

Ingle 2010Cohort study with no clear comparison between standard level/model of care and a decentralised model

Lambdin 2013Intervention being evaluated was integration of care vs vertical care, both occurred at primary care setting.

Leon 2011Randomised controlled trial done in high income country (Spain).

Shumbusho 2009Cohort (task shifting) with no comparison group.

Stein 2007Qualitative data from health care workers only.

Tene 2013Cohort study with no clear comparison between standard level/model of care and a decentralised model

 
Characteristics of studies awaiting assessment [ordered by study ID]
Assefa 2012b

Methods

Participants

Interventions

Outcomes

NotesPresentation at International AIDS Conference, 2012. Awaiting additional information from authors. Querying whether this a sub-study within Assefa 2012 or a different population.

Labhart 2012

MethodsData from International epidemiologic databases to evaluate AIDS in Southern Africa network (IeDEA-SA). Programmatic data

Participants9 Hospitals and 40 health centres in 4 countries, 13 100 patients on ART in 2011

Inclusion criteria: >16 years old at start of ART, no previous ART exposure

Baseline characteristics well balanced for sex and age, but not for CD4+ cell counts which were lower at hospital and WHO clinical stages which were more advanced at the hospitals

Decentralisation model currently underway in Lesotho

InterventionsART received at nurse run health centres

OutcomesLoss to follow-up defined as not returning to clinic >= 6 months, mortality.

NotesOral presentation at the International AIDS Conference, 2012. Additional data regarding loss to follow-up needed.

Miyano 2012

Methods

Participants

Interventions

Outcomes

NotesPresentation at International AIDS Conference, 2012. Seeking additional information about publication of this data to assess eligibility.

Morsheimer (unpublished)

MethodsRetrospective cohort

ParticipantsChildren eligible for antiretroviral therapy in South Africa.

InterventionsInitiation and maintenance by paediatric medical officers in health centres (enhanced) compared to initiation at an advanced hospital by paediatric doctors and down referral to health centres

OutcomesMortality, retention, CD4 count

NotesAwaiting feedback from author about outcomes of interest

Van Dijk 2012

MethodsCohort study in children

Before and after results of decentralisation from hospital to 'outreach' site

ParticipantsChildren in paediatric cohort in rural Zambia

InterventionsDecentralisation to outreach site, not clear when initiation of ART occurred

OutcomesCost, travel time, death, loss to follow-up, viral load

NotesOral presentation at the International AIDS Conference, 2012. Concludes that outreach group less likely to achieve virological suppression, but travel costs and times lower. Need additional information from authors regarding study design and whether the arms of the study were evaluated contemporaneously.

 
Characteristics of ongoing studies [ordered by study ID]
NCT 01414413

Trial name or titleHome assessment and initiation of ART: a cluster-randomised controlled trial in Blantyre, Malawi

MethodsRandomised open-label parallel arm trial

ParticipantsAdults >18 years of age, HIV positive and eligible for ART

InterventionsIntervention: Home assessment and initiation of ART

Control: Clinic-based ART assessment and initiation

OutcomesPrimary outcome: Antiretroviral initiation within first 6 months

Secondary outcomes: Uptake of home-based HIV testing, disclosure of HIV results, retention on ART, adherence to ART, mortality.

Starting dateJanuary 2012

Contact informationPeter MacPherson, p.macpherson@liverpool.ac.za

Notes

 
Comparison 1. Partial decentralisation - initiation in hospital, maintenance at health centre

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Death or lost to care (12 months)439090Risk Ratio (IV, Random, 95% CI)0.46 [0.29, 0.71]

    1.1 Adults
229492Risk Ratio (IV, Random, 95% CI)0.49 [0.21, 1.12]

    1.2 Children
11505Risk Ratio (IV, Random, 95% CI)0.45 [0.27, 0.74]

    1.3 Adults and children
18093Risk Ratio (IV, Random, 95% CI)0.39 [0.35, 0.43]

 2 Lost to care6Risk Ratio (IV, Random, 95% CI)Subtotals only

    2.1 Lost to care (6 months)
328699Risk Ratio (IV, Random, 95% CI)0.99 [0.56, 1.76]

    2.2 Lost to care (12 months)
439090Risk Ratio (IV, Random, 95% CI)0.55 [0.45, 0.69]

    2.3 Lost to care (24 months)
1543Risk Ratio (IV, Random, 95% CI)0.0 [0.0, 0.0]

 3 Death6Risk Ratio (IV, Random, 95% CI)Subtotals only

    3.1 Death (6 months)
328699Risk Ratio (IV, Random, 95% CI)0.52 [0.19, 1.41]

    3.2 Death (12 months)
439090Risk Ratio (IV, Random, 95% CI)0.34 [0.13, 0.87]

    3.3 Death (24 months)
1543Risk Ratio (IV, Random, 95% CI)0.04 [0.00, 0.58]

 4 Cost of travelOther dataNo numeric data

    4.1 cost of travel
Other dataNo numeric data

 
Analysis 1.4 Comparison 1 Partial decentralisation - initiation in hospital, maintenance at health centre, Outcome 4 Cost of travel.
Cost of travel

StudyDown referred patientHospital care patientP-value

cost of travel

Humphreys 2010Average cost for follow up care USD 0.74Average cost for follow up care USD 1.5P = 0.001

 
Comparison 2. Full decentralisation - initiation and maintenance in health centre

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Death or lost to care (12 months)456360Risk Ratio (IV, Random, 95% CI)0.70 [0.47, 1.02]

    1.1 Adults
352286Risk Ratio (IV, Random, 95% CI)0.62 [0.39, 0.99]

    1.2 Adults and children
14074Risk Ratio (IV, Random, 95% CI)0.97 [0.82, 1.15]

 2 Lost to care6Risk Ratio (IV, Random, 95% CI)Subtotals only

    2.1 Lost to care (6 months)
251261Risk Ratio (IV, Random, 95% CI)0.53 [0.26, 1.10]

    2.2 Lost to care (12 months)
456360Risk Ratio (IV, Random, 95% CI)0.30 [0.17, 0.54]

    2.3 Lost to care (24 months)
461445Risk Ratio (IV, Random, 95% CI)0.50 [0.36, 0.71]

 3 Death6Risk Ratio (IV, Random, 95% CI)Subtotals only

    3.1 Death (6 months)
250000Risk Ratio (IV, Random, 95% CI)0.84 [0.35, 2.00]

    3.2 Death (12 Months)
455099Risk Ratio (IV, Random, 95% CI)1.10 [0.63, 1.92]

    3.3 Death (24 months)
460184Risk Ratio (IV, Random, 95% CI)0.64 [0.39, 1.06]

 
Comparison 3. Decentralisation - from the facility to the community for antiretroviral maintenance therapy

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Death or lost to care (12 months)2709Risk Ratio (IV, Random, 95% CI)0.95 [0.62, 1.46]

 2 Lost to care3Risk Ratio (IV, Random, 95% CI)Subtotals only

    2.1 Lost to care (6 months)
1385Risk Ratio (IV, Random, 95% CI)1.49 [0.81, 2.74]

    2.2 Lost to care (12 months)
2709Risk Ratio (IV, Random, 95% CI)0.81 [0.30, 2.21]

    2.3 Lost to care (24 months)
1385Risk Ratio (IV, Random, 95% CI)0.74 [0.46, 1.20]

 3 Death3Risk Ratio (IV, Random, 95% CI)Subtotals only

    3.1 Death (6 months)
1385Risk Ratio (IV, Random, 95% CI)1.44 [0.81, 2.57]

    3.2 Death (12 months)
2709Risk Ratio (IV, Random, 95% CI)1.03 [0.64, 1.65]

    3.3 Death (24 months)
1385Risk Ratio (IV, Random, 95% CI)1.50 [0.91, 2.47]

 4 Cost to patientOther dataNo numeric data

 
Analysis 3.4 Comparison 3 Decentralisation - from the facility to the community for antiretroviral maintenance therapy, Outcome 4 Cost to patient.
Cost to patient

StudyHome based careHospital based care

Jaffar 2009total 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 2010Transport cost $0.74/ visit for home based careTransport cost $1.5/ visit for facility based care

 
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

OutcomesIllustrative comparative risks* (95% CI)Relative effect
(95% CI)
No of Participants
(studies)
Quality of the evidence
(GRADE)
Comments

Assumed riskCorresponding risk

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

Death or lost to care
Follow-up: 12 months
218 per 1000100 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 100074 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 100028 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.
 
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

OutcomesIllustrative comparative risks* (95% CI)Relative effect
(95% CI)
No of Participants
(studies)
Quality of the evidence
(GRADE)
Comments

Assumed riskCorresponding risk

ControlAntiretroviral therapy be started and maintained in health centre

Death or lost to care
Follow-up: 12 months
365 per 1000256 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 100081 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 1000106 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.
 
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

OutcomesIllustrative comparative risks* (95% CI)Relative effect
(95% CI)
No of Participants
(studies)
Quality of the evidence
(GRADE)
Comments

Assumed riskCorresponding risk

ControlDecentralisation from the facility to the community for antiretroviral maintenance therapy

Death or lost to care
Follow-up: 12 months
106 per 1000101 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 100021 per 1000
(8 to 57)
RR 0.81
(0.3 to 2.21)
709
(2 studies)
⊕⊕⊕⊝
moderate1,2

Death
Follow-up: 12 months4
ModerateRR 1.03
(0.64 to 1.65)
709
(2 studies)
⊕⊕⊕⊝
moderate1,2

55 per 100057 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.
 
Table 1. Health service nomenclature in lower- and middle-income countries

TierHighest cadreTerms often usedFacility and staffEquipment facilities

CommunityIndividual with maximum of few months training; paid or unpaid1a. Family led careFamily member 

 1b. Village volunteerTrained volunteer; health assistantsHIV tests, counselling,  replenish drugs

 1c. Primary care clinicNurse aide or community health worker with a few months training 

Health centreclinical officer or nurse (2+ years training)Health centres; district hospitalsPurpose built with at least one paramedic or nurse with some health assistantsHIV 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 hospitalsPurpose 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

HospitalDoctorHealth centres; district hospitalsPurpose built with at least one medical doctor with nurses / paramedics and assistantsCD4 count

Medicines

Not viral load

Hospital (advanced)Specialist doctorDistrict hospital; referral hospitalPurpose built with at least 2 specialist doctors with nurses / paramedics and assistantsViral load and full investigations

 
Table 2. Models of HIV care

Our termInitiationFollow-up

Standard hospital modelHospitalHospital

Partial decentralisationHospitalHealth centre

Full decentralisationHealth centreHealth centre

Full decentralisation with regular hospital supportHealth centre (weekly clinics with hospital staff)Health centre (weekly clinics with hospital staff)

CommunityPrimary (tier 1c)

Health centre

 
Primary (tier 1c)

(monitor six monthly by health centre)

 
Table 3. Description of the models of care of included studies

Models of care Provider detailsLaboratory facilitiesCommunity supportTraining in ART initiation and maintenanceSupervision or mentoringReferral







Partial decentralisation

Bock 2008Health centres (enhanced)Doctorsyesnot statednot statedspecialists availableyes

Hospital (advanced)Doctorsyesnot statedyesspecialists availablenot applicable

Brennan 2011Health centresPrimary health care nursesnot statednot statedyes yes - telephonicyes - to hospital

 HospitalsDoctorsnot statednot statednot applicablenot applicablenot applicable

Chan 2010Health centresNurses and health surveillance assistantsno Expert patientsyes yes - from hospitalnot stated

 HospitalsClinical officers, nurses and doctorsyesHome-based care volunteersnot applicablenot applicablenot stated

Fatti 2010Health centresDoctorsyesCommunity-based adherence counsellorsnot statednot statednot stated

 HospitalsDoctorsyesnot statednot statednot statednot stated

Hansudewechakul 2012health centresNursesyesyesyesyesnot stated

HospitalDoctorsyesyesyesnot applicablenot stated

Humphreys 2010Health centresNursesnonot statedyesyes - monthly visit from nurse and counselloryes

HospitalDoctorsyesnot statednot applicablenot applicablenot applicable

Full decentralisation

Assefa 2012Health centresHealth officers, nursenot statedCommunity health workers, adherence counselling, defaulter tracing, referral and linkage between facilitiesnot statednot statedyes - to hospital

 HospitalsDoctorsnot statednone not statednot statednot applicable

Balcha 2010Health centresHealth officers, nurses, data clerk, pharmacy techniciansnot statednot statednot statednot statedyes - to hospital

 HospitalsNurses, data clerks, pharmacistsnot statednot statednot statednot statednot applicable

Bedelu 2007Health centresNurses noCommunity health workers, adherence support, defaulter tracingyes yes - mobile teamyes - to hospital

 HospitalsDoctorsyesnonot statednot applicablenot applicable

Fayorsey 2013health centresdoctors and nurses8/182 sites CD4 machinesvariable by sitenot statednot statedyes

Hospitalsdoctors and nurses54/92 sites Cd4 machinesvariable by sitenot statednot statednot applicable

Massaquoi 2009Health centresMedical assistants and nurseyesyesyes yesyes - to hospital

 HospitalsDoctorsyesnot statedyes not applicablenot applicable

McGuire 2012Health centresClinical officers, nurses and medical assistantsyesyesyesnot statedyes

HospitalsClinical officers and nursesyesyesnot statednot statednot applicable

Odafe 2012HospitalsMedical doctorsyesyesnot statednot statednot stated

Hospitals (advanced)Medical specialistsyesnot statednot statednot applicablenot applicable

Decentralisation from facility to community 

JaffarCommunityField officersnonot statedyes yesyes 

 Health centresClinical staffyesnot statedyes yesnot applicable

KippCommunityUnpaid volunteers, >18 years old and literate noTreatment supporter to assist with adherenceyes yes yes

 Health centresDoctors yes no not applicable not statednot applicable 

SelkeCommunityCommunity care co-ordinatorsnoComputer aided devicesyes yesyes

 Health centresClinical officers, doctor (1 day/ week)yesnonot applicablenot applicablenot applicable