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 Tene and Elaine 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 HIV treatment 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 HIV care 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 ---- Total # children initiating ART at PHFs and SHFs Proportion of children initiating ART at PHFs Proportion of children initiating ART at SHFs 17% 44% 83% 56% 1100 750 Mar 08 Sep 08 Mar 09 Sep 09 Mar 10

9. Facility Characteristics PHFsSHFsp -value Total # of facilities18292 Program size137 (IQR:63-242) 536 (IQR:214-1079) <.0001 Program maturity (quarters) 8 (IQR:5-9) 14 (IQR:10-18) <.0001 Person years of ART during Jan 08-Mar 10 9.13 (IQR: 4-20) 86.75 (IQR: 27-198) <.0001 CD4 machine on site14 (8%)54 (59%)<.0001 Mean # FTE nurses1.6 (Range:0-13)2.1 (Range:0-24)0.1107 Mean # FTE physicians0.3 (Range:0-6)0.9 (Range:0-5)<.0001 Median proportion of children < 24mos initiated on ART 0%(IQR: 0-46)17% (IQR:0-37)<.0001

10. Univariate Analysis PHFsSHFs p- value Total # of facilities 18292 Average quarterly death/100py on ART 5.2/100 py6.0/100py0.0013 Average quarterly LTFU/100py on ART 9.8/100 py20.2/100py0.0003 Average quarterly transfer out/100py on ART 9.4/100py12.7/100py0.7854

11. Multivariate Analysis LTFUDeath ARR*p-valueARR*p-value Facility type (Ref=Secondary) Primary 0.550.0220.660.028 Country (Ref=Rwanda) Tanzania Mozambique Kenya Lesotho 4.16 7.33 12.08 16.13 <.0001 2.70 2.21 2.00 2.42 0.001 <.0001 0.0009 <.0001 *Adjusted Rate Ratio 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