ArticleThe Pediatric infectious disease journal2016
Decentralizing Access to Antiretroviral Therapy for Children Living with HIV in Swaziland.
Article in The Pediatric infectious disease journal, 2016. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 6 papers, 3 of them syntheses that pooled it.
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The trial behind it
Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.
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Who cites it
6 citing papers in PubMed, 3 syntheses or guidelines pooled it.
- HIV-related mortality time trends among children and young adolescents on antiretroviral therapy by age, treatment duration, and region: a systematic review and meta-regression analysis.The lancet. HIV · 2025Pooled it
- 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.Global health action · 2019Pooled it
- Specification of implementation interventions to address the cascade of HIV care and treatment in resource-limited settings: a systematic review.Implementation science : IS · 2017Pooled it
- Investigating strategies to enhance access to HIV services among children in Malawi: A multifaceted research approach, study protocol.PloS one · 2026Article
- Clinical outcomes in children and adolescents initiating antiretroviral therapy in decentralized healthcare settings in Zimbabwe.Journal of the International AIDS Society · 2017Article
- High risk of loss to follow-up among South African children on ART during transfer, a retrospective cohort analysis with community tracing.Journal of the International AIDS Society · 2017Article
Corrections and comments
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Authors and funding
11 authors.
Funding
Abstract
backgroundIn 2007, Swaziland initiated a hub-and-spoke model for decentralizing antiretroviral therapy (ART) access for HIV-infected children (<15 years old). Decentralization was facilitated through (1) down referral of stable children on ART from overburdened central facilities (hubs) to primary healthcare clinics (spokes) and (2) pediatric ART initiation at spokes (spoke initiation).
methodsWe conducted a nationally representative retrospective cohort study among children starting ART during 2004-2010 to assess effect of down referral and spoke initiation on rates of loss to follow-up (LTFU), death and attrition (death or LTFU). Twelve of 28 pediatric ART hubs were randomly selected using probability-proportional-to-size sampling. Seven selected facilities had initiated hub-and-spoke decentralization by study start; at these facilities, 901 of 1893 hub-initiated and maintained (hub-maintained) children and 495 of 1105 down-referred or spoke-initiated children were randomly selected for record abstraction. At the 5 hub-only facilities, 612 of 1987 children were randomly selected. Multivariable proportional hazards regression was used to estimate adjusted hazard ratios (AHR) for effect of down referral (a time-varying covariate) and spoke initiation on outcomes.
resultsAmong 2008 children at ART initiation, median age was 5.0 years, median CD4% 12.0%, median CD4 count 358 cells/µL and median weight-for-age Z score -1.91. Controlling for known confounders, down referral was strongly protective against LTFU (AHR: 0.40; 95% confidence interval: 0.20-0.79) and attrition (AHR: 0.46; 95% confidence interval: 0.26-0.83) but not mortality. Compared with hub-only children or hub-maintained children, spoke-initiated children had similar outcomes.
conclusionsDecentralization of pediatric ART through down referral and spoke initiation within a hub-and-spoke system should be continued and might improve program outcomes.
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