Many people living with HIV who need antiretroviral therapy are unable to access or remain in care. This is often because of the time and cost required to travel to health centres. One approach to facilitating access and retention in care is to provide antiretroviral therapy close to people’s homes, ‘decentralising’ treatment from hospitals to health centres or even to the community. We wanted to assess whether decentralisation of antiretroviral therapy reduced the number of people lost to follow-up. Because loss to follow-up in HIV programmes is known to include some people who have died, our main outcome of interest was 'attrition', which is the number of people who have either died or been lost to follow-up.
We searched for studies up to March 2013. We found 16 studies, including two high quality randomised controlled trials and 14 studies collecting data from HIV care programmes. All but one study was conducted in Africa. The study participants included both adults and children who were followed-up for up to two years.
We describe three types of care:
- Partial decentralisation: starting antiretroviral therapy at the hospital, then moving to a health centre to continue treatment
- Full decentralisation: starting and continuing treatment at a health centre
- Providing antiretroviral therapy in the community: antiretroviral therapy is started at a health centre or hospital and thereafter provided in the community
We found that if antiretroviral therapy was started at a hospital and continued in a health centre (partial decentralisation), there was probably less attrition and fewer patients were lost to care after one year (four studies, 39 090 patients).
Where antiretroviral therapy was started and continued at a health centre (full decentralisation), there was probably no difference in the number of deaths and patients lost to follow-up (attrition), but overall, there were probably fewer patients lost to care after one year (four studies, 56 360 patients).
If antiretroviral therapy was provided in the community, by trained volunteers, there was probably no difference detected in death or losses to care when compared to care provided at a health centre after one year (two studies, 1 453 patients).
Overall, none of the models of decentralisation led to worse health outcomes. The research indicates that fewer patients are lost to care when they are continued on antiretroviral therapy at health centres rather than in hospitals. The research also did not detect a difference in the numbers of patients lost to care when they are treated in the community rather than in a health facility.