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Role of Primary Health Care Centers in Decentralization of Pediatric Care and Treatment

Role of Primary Health Care Centers in Decentralization of Pediatric Care and Treatment . Ruby Fayorsey , Suzue Saito, Rosalind J. Carter , Eduarda Gusmao, Milembe Panya, Koen Frederix , Emily Koech-Keter, Gilbert Tene and Elaine J. Abrams ICAP-Columbia University

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Role of Primary Health Care Centers in Decentralization of Pediatric Care and Treatment

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  1. Role of Primary Health Care Centers in Decentralization of Pediatric Care and Treatment Ruby Fayorsey, Suzue Saito, Rosalind J. Carter, Eduarda Gusmao, Milembe Panya, Koen Frederix ,Emily Koech-Keter, Gilbert TeneandElaine J. Abrams ICAP-Columbia University Mailman School of Public Health WEAD0102

  2. Background • Pediatric HIV care has been implemented predominantly in secondary and tertiary level facilities because of lack of pediatric expertise and limited human resources • Decentralization of HIV care to primary health facilities is considered the cornerstone of HIVtreatment scale-up • Conflicting reports of ART effectiveness between primary and secondary/tertiary health care facilities* *Fatti, et al. PLoS 2010, Bock, et al. Trans R Soc Trop Med Hyg,2008, Boyer et al. AIDS 2010, Massaquoi, et al. Trans R Soc Trop Med Hyg, 2009

  3. Objectives • Describe trends in pediatric enrollment in HIV care and ART initiation at primary health facilities (PHFs) and secondary/tertiary health facilities (SHFs) • Compare patient outcomes (lost to follow-up [LTFU] and mortality rates) between PHFs and SHFs

  4. Methods (1) • Quarterly reported aggregate program data from 274 ICAP-supported public facilities in Kenya, Lesotho, Mozambique, Rwanda and Tanzania • PHFs (health centers or clinics) • SHFs (district, provincial, regional hospitals) • Included children <15 years of age enrolled between January 2008 to March 2010 • Excluded data from: • Pediatric Centers of Excellence (n=6) • Private health facilities (n=20) • New facilities if < 1 year of data (n=136)

  5. Methods (2) • Main Outcomes: • Pediatric enrollment in HIVcare and ART initiation • LTFU per 100 person-years (py) on ART • Mortality / 100 py on ART • Covariates: • Facility type, program size, program maturity, CD4 machine on site, FTE nurses and clinicians, % children < 24mos, and country • Statistical Analysis: • Univariate and multivariate analysis • Relative risk regression model and also accounted for correlated data

  6. Trend in Facilities (January 2008-March 2010) • The number of ICAP supported facilities increased from 128 to 274 • PHFs increased 3-fold from 56 to 182 • 64% of the PHFs were rural • SHFs increased by 30% from 72 to 92 • 64% of the SHFs were urban

  7. Pediatric Enrollment (January 2008- March 2010) • A total of 17,155 children were enrolled in care and 8,475 initiated ART • 10,901 (64%) of new pediatric enrollees and 6,032 (71%) of children initiating ART were at SHFs • SHFs accounted for only ⅓ of facilities supported • A total of 4,948 children <24mos were enrolled in care • SHFs accounted for 3,069 (62%) in care and 1,510 (69%) on ART

  8. Number and proportion of children initiating ART at PHFs and SHFs 1100 83% 750 56% 44% 17% Mar 08 Sep 08 Mar 09 Sep 09 Mar 10 ----Total # children initiating ART at PHFs and SHFs Proportion of children initiating ART at PHFs Proportion of children initiating ART at SHFs

  9. Facility Characteristics

  10. Univariate Analysis

  11. Multivariate Analysis Adjusted for site type, program size, program maturity, CD4 machine on site, % children < 24 months, FTE physician and (country)

  12. Conclusion (1) • Over the 2 year period the number of ICAP supported PHFs increased 3-fold resulting in 6,254 additional children enrolled in HIV care • This increase in number of PHFs resulted in an increase in the proportion of children newly initiating ART at PHFs • However, SHFs still account for majority of the children enrolled in care, and receiving antiretrovirals and the majority of infants initiating ART

  13. Conclusion (2) • Lost to follow-up and mortality was lower in PHFs compared to SHFs • PHFs play an important role in expanding the capacity for the care of HIV-infected children • Further research is needed to advance our understanding of the optimal models for delivering pediatric HIV care and treatment

  14. Acknowledgements • ICAP leadership • Clinical Unit- ICAP NY • ICAP clinical officers in Kenya, Lesotho, Mozambique, Rwanda and Tanzania • ICAP-Mozambique, ICAP-Kenya, ICAP-Rwanda, ICAP-Tanzania and ICAP-Lesotho

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