Role of Primary Health Care Centers in Decentralization of Pediatric Care and Treatment

Ruby Fayorsey, Suzue Saito, Rosalind J. Carter, Eduarda Gusmao, Milembe Panya, Koen Frederix , Emily Koech-Keter,

Gilbert Tene and Elaine J. AbramsICAP-Columbia University

Mailman School of Public Health

WEAD0102

Background

• Pediatric HIV care has been implemented predominantly in secondary and tertiary level facilities because of lack of pediatric expertise and limited human resources

• Decentralization of HIV care to primary health facilities is considered the cornerstone of HIV treatment scale-up

• Conflicting reports of ART effectiveness between primary and secondary/tertiary health care facilities**Fatti, et al. PLoS 2010, Bock, et al. Trans R Soc Trop Med Hyg,2008,

Boyer et al. AIDS 2010, Massaquoi, et al. Trans R Soc Trop Med Hyg, 2009

Objectives

• Describe trends in pediatric enrollment in HIV care and ART initiation at primary health facilities (PHFs) and secondary/tertiary health facilities (SHFs)

• Compare patient outcomes (lost to follow-up [LTFU] and mortality rates) between PHFs and SHFs

Methods (1)• Quarterly reported aggregate program data from 274

ICAP-supported public facilities in Kenya, Lesotho, Mozambique, Rwanda and Tanzania • PHFs (health centers or clinics)• SHFs (district, provincial, regional hospitals)

• Included children <15 years of age enrolled between January 2008 to March 2010

• Excluded data from:– Pediatric Centers of Excellence (n=6)– Private health facilities (n=20)– New facilities if < 1 year of data (n=136)

Methods (2)• Main Outcomes:

– Pediatric enrollment in HIV care and ART initiation– LTFU per 100 person-years (py) on ART – Mortality / 100 py on ART

• Covariates:– Facility type, program size, program maturity, CD4

machine on site, FTE nurses and clinicians, % children < 24mos, and country

• Statistical Analysis:— Univariate and multivariate analysis— Relative risk regression model and also accounted for

correlated data

Trend in Facilities (January 2008-March 2010)

• The number of ICAP supported facilities increased from 128 to 274 – PHFs increased 3-fold from 56 to 182

• 64% of the PHFs were rural– SHFs increased by 30% from 72 to 92

• 64% of the SHFs were urban

Pediatric Enrollment (January 2008- March 2010)

• A total of 17,155 children were enrolled in care and 8,475 initiated ART

• 10,901 (64%) of new pediatric enrollees and 6,032 (71%) of children initiating ART were at SHFs– SHFs accounted for only ⅓ of facilities supported

• A total of 4,948 children <24mos were enrolled in care– SHFs accounted for 3,069 (62%) in care and 1,510

(69%) on ART

Number and proportion of children initiating ART at PHFs and SHFs

---- Total # children initiating ART at PHFs and SHFs Proportion of children initiating ART at PHFs Proportion of children initiating ART at SHFs

17%

44%

83%

56%

1100

750

Mar 08 Sep 08 Mar 09 Sep 09 Mar 10

Facility CharacteristicsPHFs SHFs p -value

Total # of facilities 182 92Program size 137

(IQR:63-242)536

(IQR:214-1079) <.0001

Program maturity (quarters)

8 (IQR:5-9)

14 (IQR:10-18)

<.0001

Person years of ART during Jan 08-Mar 10

9.13 (IQR: 4-20)

86.75 (IQR: 27-198) <.0001

CD4 machine on site 14 (8%) 54 (59%) <.0001Mean # FTE nurses 1.6 (Range:0-13) 2.1 (Range:0-24) 0.1107Mean # FTE physicians 0.3 (Range:0-6) 0.9 (Range:0-5) <.0001

Median proportion of children < 24mos initiated on ART

0%(IQR: 0-46) 17% (IQR:0-37) <.0001

Univariate Analysis

PHFs SHFs p- valueTotal # of facilities 182 92 Average quarterly death/100py on ART 5.2/100 py 6.0/100py 0.0013

Average quarterly LTFU/100py on ART 9.8/100 py 20.2/100py 0.0003Average quarterly transfer out/100py on ART

9.4/100py 12.7/100py 0.7854

Multivariate AnalysisLTFU Death

ARR* p-value ARR* p-valueFacility type (Ref=Secondary)Primary

0.55 0.022 0.66 0.028

Country (Ref=Rwanda)TanzaniaMozambiqueKenyaLesotho

4.167.3312.0816.13

<.0001<.0001<.0001<.0001

2.702.212.002.42

0.001<.00010.0009<.0001

*Adjusted Rate Ratio

Adjusted for site type, program size, program maturity, CD4 machine on site, % children < 24 months, FTE physician and (country)

Conclusion (1)• Over the 2 year period the number of ICAP

supported PHFs increased 3-fold resulting in 6,254 additional children enrolled in HIV care – This increase in number of PHFs resulted in an

increase in the proportion of children newly initiating ART at PHFs

• However, SHFs still account for majority of the children enrolled in care, and receiving antiretrovirals and the majority of infants initiating ART

Conclusion (2)• Lost to follow-up and mortality was

lower in PHFs compared to SHFs• PHFs play an important role in expanding

the capacity for the care of HIV-infected children

• Further research is needed to advance our understanding of the optimal models for delivering pediatric HIV care and treatment

Acknowledgements

• ICAP leadership• Clinical Unit- ICAP NY

• ICAP clinical officers in Kenya, Lesotho, Mozambique, Rwanda and Tanzania

• ICAP-Mozambique, ICAP-Kenya, ICAP-Rwanda, ICAP-Tanzania and ICAP-Lesotho