Treatment Outcomes in a Decentralized Antiretroviral Therapy Program: A Comparison of Two Levels of Care in North Central Nigeria

Abstract

Background. Decentralization of antiretroviral therapy (ART) services is a key strategy to achieving universal access to treatment for people living with HIV/AIDS. Our objective was to assess clinical and laboratory outcomes within a decentralized program in Nigeria. Methods. Using a tiered hub-and-spoke model to decentralize services, a tertiary hospital scaled down services to 13 secondary-level hospitals using national and program guidelines. We obtained sociodemographic, clinical, and immunovirologic data on previously antiretroviral drug na¨ıve patients aged ≥15 years that received HAART for at least 6 months and compared treatment outcomes between the prime and satellite sites. Results. Out of 7,747 patients, 3729 (48.1%) were enrolled at the satellites while on HAART, prime site patients achieved better immune reconstitution based on CD4+ cell counts at 12 (𝑃 < 0.001) and 24 weeks (𝑃 < 0.001) with similar responses at 48 weeks (𝑃 = 0.11) and higher rates of viral suppression (<400 c/mL) at 12 (𝑃 < 0.001) and 48 weeks (𝑃 = 0.03), but similar responses at 24 weeks (𝑃 = 0.21). Mortality was 2.3% versus 5.0% (𝑃 < 0.001) at prime and satellite sites, while transfer rate was 8.7% versus 5.5% (𝑃 = 0.001) at prime and satellites. Conclusion. ART decentralization is feasible in resource-limited settings, but efforts have to be intensified to maintain good quality of care.