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

Abstract

Background: Decentralisation of antiretroviral therapy has been implemented to scale up HIV care provision for patients in resource-limited countries. Youth living with HIV demonstrate the poorest care outcomes, compared to other age groups.Objectives: To systematically evaluate evidence on the effects of decentralising facility-based HIV care on care outcomes for youth living with HIV in low- and middle-income countries.Methods: A systematic review was conducted through 12 electronic databases of peer-reviewed articles, conference abstracts, and grey literature; contacting relevant experts; and hand-searching references. Records were included if they were published after 1 January 1996 (advent of triple-drug ART) and reported health outcomes for decentralised and centralised care, separately, or evaluated the effect of decentralised care on care outcomes. Two authors independently screened search results. When age-disaggregated data (10–24 years old) were required for inclusion, we contacted study authors for data abstraction. Implementation fidelity of decentralisation, study quality, and risk of bias was assessed using the TIDieR checklist, CASP checklists, and ROBINS-I tool, respectively.Results: Of 11 potentially eligible studies, two studies from sub-Saharan Africa met inclusion criteria after data disaggregation by age. The studies and abstracted data were insufficiently homogenous in implementation and study design to justify meta-analysis. However, evidence suggests the potential for decentralised care to result in at least equivalent attrition-related outcomes (retention in care and mortality) for youth within decentralised HIV care. Limited sample size and significant selection and allocation bias confound clear, generalisable conclusions for youth living with HIV in resource-limited settings.Conclusions: There is a paucity of evidence for the effects of decentralising HIV care for youth living in resource-limited settings, particularly recent evidence reflective of the current HIV care landscape. Further work is required to rigorously analyse the effects of decentralising HIV care to inform policymakers and care providers, particularly as demand for HIV care in this population grows.

Clinic and care: associations with adolescent antiretroviral therapy adherence in a prospective cohort in South Africa

“…This suggests potential positive implications for sub-Saharan Africa's decentralization from hospital-based ART provision to primary care, which often reduces patient travel burden. Systematic reviews suggest – from limited data – that decentralization may support adolescent retention in care [ 63 , 34 ]. WHO Global Standards for Quality Healthcare Services for Adolescents have identified insufficient respect for adolescent confidentiality and privacy as a major barrier for service access [ 64 ].…”

Interventions to Improve Treatment Outcomes among Adolescents on Antiretroviral Therapy with Unsuppressed Viral Loads: A Systematic Review

“…The quality of evidence and risk of bias for the non-randomized control trials and the randomized control trials were assessed using the Risk of Bias in Non-randomized Studies of Interventions (ROBINS-I) Assessment Tool and the Critical Appraisal Skills Programme (CASP) Checklist, respectively [ 23 ]. The GRADE considerations were used to assess the certainty of evidence on the interventions and outcomes reported by each included study, considering the risk of bias, consistency in effects, imprecision, indirectness, and publication bias [ 24 , 25 ].…”

Rate of virological failure and HIV-1 drug resistance among HIV-infected adolescents in routine follow-up on health facilities in Cameroon

“…In addition, the increased risk of VF in ALHIV living out of the town where they received ART could be due to the long distance traveled to reach the health facility and the high cost of transport which constitutes an obstacle to access to health services. Decentralization of HIV care for children and adolescents must continue in our context to facilitate the provision of differentiated services in health centers close to communities in accordance with WHO guidelines [ 24 ].…”