Decentralisation of care reduces HIV and TB-related deaths, illness in Swaziland and Uganda

Mara Kardas-Nelson
Published: 19 December 2013

New studies from eastern and southern Africa add to  mounting evidence that antiretroviral therapy (ART) has a profound impact on reducing opportunistic infections, and that decentralised and integrated TB and HIV care increases use of services and ART uptake, thus bettering overall patient outcomes.

Impact of decentralised care in Swaziland

Presenting at the 17th International Conference on AIDS and STIs in Africa (ICASA) in Cape Town, South Africa, last week, Bernhard Kerschberger of Médecins Sans Frontières (MSF) in Swaziland showed that by integrating TB/HIV care, decentralising care from three secondary health facilities to 22 primary healthcare clinics, and utilising a nurse-led rather than doctor-centric model, MSF and the Ministry of Health (MoH) were able to radically decrease the incidence of HIV, TB and some other co-morbidities in the Shishelweni region from 2007 to 2013.

Presenting a retrospective analysis of 2.5 million outpatient consultations at 33 health centres over the six and a half year period, and TB treatment initiation data from January 2009 to March 2012, Kerschberger says that, compared with 2007 baseline data, there was a 67% decrease in TB risk and a 69% risk decrease for persistent diarrhoea in 2013. With each calendar year, there was a 13% decrease in herpes zoster, and 11% for meningitis. He said that the decreasing risk ratios are aligned with interventions aimed at decentralising care, and increasing ART uptake.

In 2006, HIV care was centralised to a few facilities and primarily conducted by doctors, and ART coverage was only 20%. From 2008 to 2010, MSF and the MoH integrated HIV and TB care, increased TB case findings, trained nurses in HIV treatment and diagnosis of opportunistic infections, administered isoniazid preventative therapy, and increased ART coverage to 45%. By 2012/2013, HIV and TB care was fully decentralised and integrated, and nurses were primarily responsible for HIV and TB care. ART coverage rates hovered around 80%.

Kerschberger notes that MSF used retrospective data for its analysis in order "to show that you can use routine data to monitor the progress of your HIV epidemic". He says that decreased rates of opportunistic infections, despite increased access and case finding activities, demonstrates that scale-up of ART in high HIV/TB prevalence settings can increase health outcomes across the population as a whole.

Impact of decentralised care in Uganda

A population survey in Northern Uganda found that decentralised HIV testing and antenatal care had a positive impact on increasing rates of HIV testing, usage of antenatal services, and ART uptake. The data was presented by Sylvia Muyingo for the Lablite Project, an initiative of the UK's Medical Research Council, which is focused on cost-effective HIV treatment and care strategies. 

Of 2115 participants who answered a survey considering HIV knowledge and uptake of services conducted from March to April 2013, 82% reported ever having tested for HIV (77% of men and 85% of women). In total, 62% of female study participants had given birth in the last five years, with 96% accessing antenatal services, 98% of whom tested for HIV at an antenatal care visit. Two-third of HIV-infected mothers and their babies had received drugs for PMTCT in last five years. Of those who were HIV positive, 97% of men and 95% of women were in care; 90% of men and 92% of women were receiving cotrimoxazole; and 68% of men and 62% of women were on ART. Of those in HIV care, 71% reported that their blood was taken in the last 12 months, 96% of whom understood that this was for CD4 testing. Those on ART were more likely to get CD4 tests. Communitymembers who were older, less educated, never married, or not earning income, were less likely to test for HIV.

While HIV testing and antenatal care were decentralised, ART provision was not, but Muyingo notes that ART rates were high despite the fact that most patients had to travel between 28 and 38 km to access ART. She says that ART rates may increase now that treatment is also being decentralised to the community level.

Aggrey Semeere of Uganda's Infectious Diseases Institute and a visiting fellow at University of California at San Francisco presented an observational study considering patients' vulnerability to Kaposi's sarcoma (KS) in Uganda and Kenya. By following a cohort of 160,000 HIV-infected adults, initially without KS, in Mbarara and Kampala, Uganda, and Eldoret, Kenya, from 2004 until 2012, the study found 1375 new cases of Kaposi's sarcoma, with an overall incidence of 260 per 100,000 person-years (the study considered any new case of KS to be one found after 30 days of clinical enrolment. KS was diagnosed either clinically or through biopsy). Rates were higher among men.

Semeere notes that those on ART experienced rates of KS much lower than those not initiated: 260 per 100,000 person-years, compared with 347 per 100,000 person-years. "ART provided to patients at these three clinics in east Africa was able to reduce the risk of KS by 80%.” Patients with the lowest CD4 count had the greatest effect from ART.

Semeere notes that Kaposi's sarcoma is the most commonly reported HIV-associated cancer in many resource-limited areas, including sub-Saharan Africa. He says that the rates of the cancer in the cohort may actually be higher than recorded, as the study was observational and did not confirm all KS results with a biopsy. As comparison, Semeere notes that the rate of prostate cancer in the U.S. is 40 per 100,000 person-years.

Given ART’s impact on rates of KS, Sameere says that countries should consider scale-up of ART. Despite its expense, it could have a cost-saving impact, as "Kaposi sarcoma is expensive in terms of chemotherapy", he said.

References

Kerschberger B et al. Temporal trends in opportunistic infections in outpatient departments and population level in the context of antiretroviral therapy scale up in Shiselweni, Swaziland. 17th International Conference on AIDS and STIs in Africa, Cape Town, abstract ADS062, 2013.

Muyingo SK et al. HIV testing, use of cotrimoxazole and ART among adults in a community level setting in northern Uganda: results from a population survey. 17th International Conference on AIDS and STIs in Africa, Cape Town, abstract ADS065, 2013.

Semeere A et al. Impact of antiretroviral therapy on Kaposi's sarcoma incidence among HIV-infected adults in East Africa. 17th International Conference on AIDS and STIs in Africa, Cape Town, abstract ADS063, 2013.