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.

KEYWORDS:

• HIV
• antiretroviral therapy
• decentralisation
• youth
• healthcare
• facility-based
• adolescents

Responsible Editor Jennifer Stewart Williams, Umeå University, Sweden

Responsible Editor Jennifer Stewart Williams, Umeå University, Sweden

Acknowledgments

We wish to thank Paul Montgomery for his advice with developing the review protocol and Elona Toska for her guidance. We also thank both Florian Scheibe and Adrienne Chan for responding to requests for additional information and age-disaggregated data from their studies.

Disclosure statement

No potential conflict of interest was reported by the authors.

Ethics and consent

Not applicable.

Paper context

To scale up care, resource-limited countries are decentralising HIV care delivery. Youth demonstrate the worst HIV outcomes of all age groups. This systematic review evaluates the effect of decentralising HIV care on youth health outcomes in low- and middle-income countries. Two studies met inclusion criteria. Both were out-dated and poorly controlled, limiting implications for the present context. This review highlights the urgent need to better understand how decentralising HIV care may affect this vulnerable population.

Additional information

Funding

RH is jointly funded through the Economic and Social Research Council [ES/J500112/1] and the Clarendon Fund [Clarendon Fund Scholarship]. JS is also funded through the Economic and Social Research Council. LC is funded by the John Fell Fund [103/757; 161/033]; the University of Oxford's ESRC Impact Acceleration Account [IAA-MT13-003/1602-KEA-189/K1311-KEA-004]; the European Research Council (ERC) under the European Union's Seventh Framework Programme [FP7/2007-2013/ERC grant agreement no 313421]; the ERC under the European Union’s Horizon 2020 research and innovation programme [ERC grant agreement no 737476]; the Leverhulme Trust [PLP-2014-095]; the UK Medical Research Council (MRC) and the UK Department for International Development (DFID) under the MRC/DFID Concordat agreement; and the Department of Health Social Care (DHSC) through its National Institutes of Health Research (NIHR) [MR/R022372/1].

Notes on contributors

Roxanna Haghighat

Study conception: RH, LC; Study design: RH; Search strategy: RH; Study screening: RH, JS; Appraisal of studies: RH; Manuscript drafting: RH; Manuscript review and finalization: RH, JS, LC. All authors have read and approved the manuscript.