Melbourne School of Population and Global Health - Theses

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Author: Rahadi, Arie × Subject: primary care ×

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    HIV care decentralization in lower- and middle-income countries: outcomes, costs, and cost effectiveness
    Rahadi, Arie ( 2018)
    Decentralized provision of HIV care continuum – from diagnosis to chronic antiretroviral treatment (ART) – at primary health care facilities (PHCFs) is a critical step towards realizing optimal care coverage in national programs of lower- and middle-income countries (LMICs). Whether such a model of provision is justified depends on considerations of effectiveness, program costs, and cost-effectiveness. This research project aims to: a) examine the effectiveness of decentralized provision of HIV testing and counseling (HTC), pre-ART (ART initiation), and long-term ART care relative to hospital provision with the following outcomes: • Cascade of service receipt in HIV testing and counseling (HTC); • The timeliness of ART initiation by baseline CD4 count and clinical stage; • Treatment adherence during ART care. b) estimate and compare ART program costs of decentralized care at PHCFs and those of hospital care; c) estimate the cost-effectiveness of decentralized provision of routine, chronic ART care relative to hospital (centralized) provision. Data from national surveys and reviews of published studies in Indonesia and sub-Saharan Africa were analyzed using multivariate statistics, meta-analysis, and model-based cost-effectiveness analysis. In HTC, pregnant women were equally likely to receive a full HTC procedure, up to post-test counseling, at both hospitals and PHCFs in four high-prevalence countries (Lesotho, Malawi, Zambia, and Zimbabwe), with a positive implication for motivating regular HTC. In pre-ART care; CD4 counts at ART initiation increased over the calendar time for both hospital and PHCF patients, with fewer patients experiencing a late HIV stage. In ART care, hospital and PHCF patients exhibited at least similar adherence to ART, indicating a non-inferior performance of decentralized provision in Indonesia. In program costs, the average cost of providing ART care for PHCF patients was not lower than hospital provision in four sub-Saharan African countries (Rwanda, Malawi, Zambia, and Ethiopia), except in Ethiopia. Cost differences were largely attributable to differential prescribing of ART regimens between facility types and minimized with a switch to the recommended regimens. In terms of cost-effectiveness, decentralizing stable ART patients from hospitals to PHCFs for routine care (down-referral) was found to be cost-effective in Ethiopia. Economically, the extra program cost represents an affordable investment to advance the performance of the existing decentralization programming and population health. HIV care decentralization redistributes the care burden across the health system without compromising patient outcomes and favorable cost-effectiveness implications. Program expansion beyond decentralization and facility-based provision may be necessary to attain optimal coverage of HIV care in many LMICs. Identifying the optimal model of decentralization for given set of program characteristics is a key research area in the direction of optimizing program outcomes and efficiency.