Distance to care, enrollment and loss to follow-up of HIV patients during decentralization of antiretroviral therapy in Neno District, Malawi: A retrospective cohort study

作者：Alyssa Bilinski, Ermyas Birru, Matthew Peckarsky, Michael E. Herce, Noel Kalanga, Christian Neumann, Gay Bronson, Stephen Po–Chedley, Chembe Kachimanga, Ryan K. McBain, James W. Keck · 发表于：PLoS ONE · 年份：2017 · DOI：10.1371/journal.pone.0185699 · 被引用次数：66 · 研究领域：HIV/AIDS Research and Interventions、Global Maternal and Child Health、HIV, Drug Use, Sexual Risk

HIV/AIDS remains the second most common cause of death in low and middle-income countries (LMICs), and only 34% of eligible patients in Africa received antiretroviral therapy (ART) in 2013. This study investigated the impact of ART decentralization on patient enrollment and retention in rural Malawi. We reviewed electronic medical records of patients registered in the Neno District ART program from August 1, 2006, when ART first became available, through December 31, 2013. We used GPS data to calculate patient-level distance to care, and examined number of annual ART visits and one-year lost to follow-up (LTFU) in HIV care. The number of ART patients in Neno increased from 48 to 3,949 over the decentralization period. Mean travel distance decreased from 7.3 km when ART was only available at the district hospital to 4.7 km when ART was decentralized to 12 primary health facilities. For patients who transferred from centralized care to nearer health facilities, mean travel distance decreased from 9.5 km to 4.7 km. Following a transfer, the proportion of patients achieving the clinic's recommended ≥4 annual visits increased from 89% to 99%. In Cox proportional hazards regression, patients living ≥8 km from a health facility had a greater hazard of being LTFU compared to patients <8 km from a facility (adjusted HR: 1.7; 95% CI: 1.5-1.9). ART decentralization in Neno District was associated with increased ART enrollment, decreased travel distance, and increased retention in care. ...