Effective Coverage for Antiretroviral Therapy in a Ugandan District with a Decentralized Model of Care

Abstract

IntroductionWhile increasing access to antiretroviral therapy (ART) is reported from many African countries, data on effective coverage particular from settings without external support or research remains scarce. We examined and report effective coverage data from a public ART program in rural Uganda.MethodsWe conducted a retrospective cohort study at all ART-providing governmental health facilities in Iganga District, Eastern Uganda. Based on all HIV patients registered between April 2004 and September 2009 (n = 4775), we assessed indicators of program performance and determined rates of retention and Cox proportional hazards for attrition. Effective ART coverage was calculated using projections (SPECTRUM software) adapted to the district demographic structure and number of people receiving ART.ResultsBy September 2009, district public sector effective ART coverage was 10.3% for adults and 1.9% for children. After a median follow-up of 26.9 months, overall ART retention was 54.7%. The probability of retention was 0.72 (95% confidence interval (CI) 0.69–0.75) at 12 and 0.58 (CI 0.54–0.62) at 36 months after ART initiation. Individual health facilities differed considerably regarding performance indicators and retention. Overall, 198 (16.9%) individual files of 1171 registered ART patients were lost. Young adult age (15–24 years) had a higher risk of attrition (HR 2.1, CI 1.4–3.2) as well as WHO stage I (HR 4.8, CI 1.9–11.8) and WHO stage IV (HR 2.5, CI 1.3–4.7). An interval ≥6 weeks between HIV testing and ART initiation was associated with a reduced risk (HR 0.6, CI 0.47–0.78).ConclusionCompared to reported national data effective ART coverage in Iganga District was low. Intensified efforts to improve access, retention in care, and quality of documentation are urgently needed. Children and young adults require special attention in the program.

The effects of decentralising antiretroviral therapy care delivery on health outcomes for adolescents and young adults in low- and middle-income countries: a systematic review

“…We identified 11 studies that were potentially eligible. All 11 studies' study samples were not limited to youths and required data to be age-disaggregated for inclusion in the review [22,[37][38][39][40][41][42][43][44][45][46]. The lead author contacted study authors for all 11 studies at the end of each record screening round, and only studies whose authors provided age-disaggregated data were included in the review.…”

“…Ultimately, we identified two studies that met the inclusion criteria because age-disaggregated data for adolescents and youth (10-24 years old) were available [37,38]. Table 1 provides a descriptive overview of the included studies.…”

“…Table 1 provides a descriptive overview of the included studies. Both studies were conducted among mixed paediatric and adult populations residing in rural sub-Saharan Africa, one in Uganda [37] and one in Malawi [38]. Within this review, study outcomes and sample characteristics are described only for adolescent and youth participants aged 10-24 at baseline in the study.…”

“…Analysed data were comprised of clinical records extracted from patient records and HIV registers. Data coverage for both studies began in 2004, but collection ended in December 2008 for the Malawian study [38] and September 2009 for the Ugandan study [37]. For adolescents and youths, available outcomes for analysis were attrition in care (including mortality) for the Ugandan study [37] and retention in care and mortality, separately, for the study in Malawi [32].…”

“…In the Iganga District of eastern Uganda, decentralisation of ART maintenance began by shifting care from the public general hospital in town to four rural health centres between December 2005 and May 2007 [37]. In February 2007, both ART [32].…”