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Provision of antiretroviral therapy to children within the public sector of South Africa

Identifieur interne : 001E97 ( Istex/Corpus ); précédent : 001E96; suivant : 001E98

Provision of antiretroviral therapy to children within the public sector of South Africa

Auteurs : Peter Bock ; Andrew Boulle ; Catherine White ; Meg Osler ; Brian Eley

Source :

RBID : ISTEX:5ECF4C9DA91FB9212471FEEBDE04B0B31FFFAAE9

English descriptors

Abstract

The South African Department of Health has embraced the primary health care approach in the provision of antiretroviral therapy (ART) to children. This paper compares clinical outcomes of children treated at primary healthcare clinics, district hospitals, and secondary and tertiary hospitals. A retrospective review of routine data captured by the provincial antiretroviral monitoring system was completed. Simplified cohort analysis was used to determine the cumulative incidence of baseline characteristics and outcomes. Data on 1741 children started at level 2 & 3, level 1 and primary healthcare clinic facilities between April 2004 and April 2006 were analysed. Kaplan–Meier survival estimates for these groups were 0.88 (95% CI 0.86–0.90), 0.94 (95% CI 0.89–0.97) and 0.94 (95% CI 0.89–0.96) at 12 months of ART, respectively, on intention-to-treat analysis. The overall cumulative proportion of children with a suppressed viral load was 73% (95% CI 69–77%) at 12 months of ART. There was no significant difference in viral load suppression rates between the three groups. This study confirms the feasibility of providing antiretrovirals at all levels of the healthcare service in the Western Cape. The higher death rates at level 2 & 3 facilities are most likely due to recruitment of sicker patients at this level.

Url:
DOI: 10.1016/j.trstmh.2008.06.010

Links to Exploration step

ISTEX:5ECF4C9DA91FB9212471FEEBDE04B0B31FFFAAE9

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<aff id="aff3">
<label>c</label>
Red Cross Children's Hospital and the School of Child and Adolescent Health, University of Cape Town, Rondebosch, Cape Town 7701, South Africa</aff>
</contrib-group>
<author-notes>
<corresp id="cor1">
<label>*</label>
Corresponding author. Present address: 7 Hares Avenue, Woodstock 7925, Cape Town, South Africa. Tel.: +27 21 447 0822.
<italic>E-mail address:</italic>
<email>peter@arkonline.org</email>
(P. Bock)</corresp>
</author-notes>
<pub-date pub-type="ppub">
<month>9</month>
<year>2008</year>
</pub-date>
<volume>102</volume>
<issue>9</issue>
<fpage>905</fpage>
<lpage>911</lpage>
<history>
<date date-type="received">
<day>27</day>
<month>8</month>
<year>2007</year>
</date>
<date date-type="rev-recd">
<day>14</day>
<month>6</month>
<year>2008</year>
</date>
<date date-type="accepted">
<day>14</day>
<month>6</month>
<year>2008</year>
</date>
</history>
<permissions>
<copyright-year>2008</copyright-year>
<copyright-holder>Royal Society of Tropical Medicine and Hygiene</copyright-holder>
</permissions>
<abstract>
<title>Summary</title>
<p>The South African Department of Health has embraced the primary health care approach in the provision of antiretroviral therapy (ART) to children. This paper compares clinical outcomes of children treated at primary healthcare clinics, district hospitals, and secondary and tertiary hospitals. A retrospective review of routine data captured by the provincial antiretroviral monitoring system was completed. Simplified cohort analysis was used to determine the cumulative incidence of baseline characteristics and outcomes. Data on 1741 children started at level 2 & 3, level 1 and primary healthcare clinic facilities between April 2004 and April 2006 were analysed. Kaplan–Meier survival estimates for these groups were 0.88 (95% CI 0.86–0.90), 0.94 (95% CI 0.89–0.97) and 0.94 (95% CI 0.89–0.96) at 12 months of ART, respectively, on intention-to-treat analysis. The overall cumulative proportion of children with a suppressed viral load was 73% (95% CI 69–77%) at 12 months of ART. There was no significant difference in viral load suppression rates between the three groups. This study confirms the feasibility of providing antiretrovirals at all levels of the healthcare service in the Western Cape. The higher death rates at level 2 & 3 facilities are most likely due to recruitment of sicker patients at this level.</p>
</abstract>
<kwd-group xml:lang="en">
<title>Keywords</title>
<kwd>Antiretroviral therapy</kwd>
<kwd>Children</kwd>
<kwd>Primary health care</kwd>
<kwd>Monitoring</kwd>
<kwd>Outcome assessment</kwd>
<kwd>Africa</kwd>
</kwd-group>
</article-meta>
</front>
<body>
<sec>
<label>1</label>
<title>Introduction</title>
<p>Since the launch of the ‘Treat 3 million by 2005’ initiative by the WHO and the ‘Unite for children, unite against AIDS’ campaign by the United Nations Children's Fund (UNICEF), an ever increasing number of children have gained access to highly active antiretroviral therapy (ART) in Africa (
<xref ref-type="bibr" rid="bib18">UNICEF, 2005</xref>
). At the end of 2006, 115 000 children, or 15% of the 780 000 estimated to be in need of treatment, were receiving ART (
<xref ref-type="bibr" rid="bib19">UNICEF, 2007</xref>
). The WHO has led the development of global treatment guidelines for children. These guidelines, adopted by many sub-Saharan African countries, are modelled on a public health approach to scaling-up care for HIV-infected children in poor countries. Unlike care models in developed countries, which emphasise specialised care augmented by comprehensive laboratory monitoring, the public health approach is grounded on standardised, simplified treatment protocols and decentralised care delivery (
<xref ref-type="bibr" rid="bib6">Gilks et al., 2006</xref>
;
<xref ref-type="bibr" rid="bib23">WHO, 2006a</xref>
).</p>
<p>The South African National Department of Health has endorsed the delivery of ART through its primary healthcare (PHC) system (
<xref ref-type="bibr" rid="bib2">Department of Health of South Africa, 2003</xref>
). The Western Cape, one of nine provinces in South Africa, has a population of approximately 4.7 million people (
<xref ref-type="bibr" rid="bib15">Statistics South Africa, 2006</xref>
). In mid 2006, the Medical Research Council of South Africa estimated that there were approximately 11 000 HIV-infected children <15 years of age in the Western Cape (
<xref ref-type="bibr" rid="bib4">Dorrington et al., 2006</xref>
). At the end of June 2007, 3109 children were receiving ART at 48 facilities in the province. The 48 facilities were distributed throughout the 25 health districts in the Western Cape (Provincial Government of the Western Cape, unpublished document, 2007).</p>
<p>Children on ART at level 3 facilities (academic hospitals) have access to comprehensive care, specialist consultation and advanced diagnostic procedures and interventions. Level 2 facilities (regional hospitals) are serviced by general paediatricians and also provide a comprehensive package of specialised care. Level 2 and 3 facilities additionally operate as referral centres for level 1 and 2 facilities, respectively (
<xref ref-type="bibr" rid="bib17">Thomas and Muirhead, 2002</xref>
). Furthermore, the three academic hospitals in Cape Town are involved in a paediatric outreach programme whereby onsite and telephone consultation at ART clinics has helped to develop and strengthen treatment capacity throughout the province. Children who are stable on ART may be transferred out to level 1 facilities for ongoing care and, similarly, ill children requiring specialist care may be transferred in to level 2 and 3 facilities.</p>
<p>Primary health care in South Africa is delivered through the district health system at level 1 facilities, which include district hospitals and PHC clinics. PHC clinics in the Western Cape comprise community health centres and clinics. District hospitals are staffed by generalist medical officers and provide a broad range of services, including comprehensive care to HIV-infected children and adults (
<xref ref-type="bibr" rid="bib17">Thomas and Muirhead, 2002</xref>
;
<xref ref-type="bibr" rid="bib22">WHO, 1998</xref>
).</p>
<p>All ART facilities in the province are capable of initiating and maintaining children on ART. The development of this paediatric treatment network accords with the WHO public health philosophy of decentralised care, thereby promoting access throughout the province.</p>
<p>The Western Cape also has a comprehensive ‘prevention of mother to child transmission’ (PMTCT) programme. HIV-infected women receive a minimum of two antiretroviral agents (dual prophylaxis). Zidovudine (AZT) is prescribed from 28 weeks gestation and nevirapine (NVP) is administered to women at the onset of labour. All HIV-exposed newborns are given a single dose of NVP and a 7-day course of AZT (
<xref ref-type="bibr" rid="bib11">Provincial Government of the Western Cape, 2002</xref>
). Following birth, infected mothers who elect to formula feed are provided with 6 months of milk powder. HIV-exposed infants are tested for HIV by PCR and are commenced on co-trimoxazole prophylaxis at 6 weeks of life. This programme has achieved vertical transmission rates of 6–7% (Provincial Government of the Western Cape, unpublished document, 2006).</p>
<p>Recent publications have begun to document the early outcomes of children on ART in Africa (
<xref ref-type="bibr" rid="bib1">Arrivé et al., 2007</xref>
;
<xref ref-type="bibr" rid="bib5">Eley et al., 2006</xref>
;
<xref ref-type="bibr" rid="bib8">Marazzi et al., 2006</xref>
;
<xref ref-type="bibr" rid="bib9">Nyandiko et al., 2006</xref>
;
<xref ref-type="bibr" rid="bib10">O’Brien et al., 2006</xref>
;
<xref ref-type="bibr" rid="bib13">Reddi et al., 2007</xref>
;
<xref ref-type="bibr" rid="bib14">Rouet et al., 2006</xref>
;
<xref ref-type="bibr" rid="bib16">The Malawi Paediatric Antiretroviral Treatment Group, 2007</xref>
;
<xref ref-type="bibr" rid="bib21">Wamalwa et al., 2007</xref>
). These studies vary in their patient composition and have included analyses of single-site cohorts, pooled data from multiple sites within one country, combined data from sites in several different countries, hospital-based cohorts, community clinic studies, and combined hospital and community cohorts. Generally, they have reported favourable short-term outcomes. To date, there has been no study from Africa comparing the early outcome of children initiated on ART at community clinics with those treated at hospital-based clinics. In the present study, we address this question by comparing outcomes of children treated with ART at PHC clinics, district hospitals and level 2 & 3 hospitals in the Western Cape Province of South Africa.</p>
</sec>
<sec sec-type="methods">
<label>2</label>
<title>Methods</title>
<p>A retrospective review of all children started on ART in the Western Cape Province and recorded in the provincial ART monitoring system between April 2004 and April 2006 was completed. Children were selected to start ART according to established clinical and immunological criteria. Children with modified WHO stage 2 or 3 disease or a low CD4 percentage irrespective of disease stage (<20% if <18 months old or <15% if >18 months old), or recurrent or prolonged hospitalisation (>4 weeks) qualified for ART. In addition, all children were required to have an identifiable caregiver who could take responsibility for administration of the medication.
<xref ref-type="fig" rid="tbl1">Table 1</xref>
<fig id="tbl1">
<label>Table 1</label>
<caption>
<p>Recommended antiretroviral treatment regimens</p>
</caption>
<graphic mimetype="image" xlink:href="102-9-905-tbl001.tif"></graphic>
</fig>
gives the preferred regimens during the study period (
<xref ref-type="bibr" rid="bib12">Provincial Government of the Western Cape, 2004</xref>
). By the end of April 2006, 39 level 1, 2 or 3 clinics within the public sector had commenced children on ART.</p>
<p>The monitoring system, developed by the
<xref ref-type="bibr" rid="bib24">WHO (2006b)</xref>
, uses paper-based ART registers at clinics to capture relevant patient information (
<xref ref-type="fig" rid="tbl2">Table 2</xref>
<fig id="tbl2">
<label>Table 2</label>
<caption>
<p>Data elements and indicators recorded in the paper-based monitoring system</p>
</caption>
<graphic mimetype="image" xlink:href="102-9-905-tbl002.tif"></graphic>
</fig>
). All patients <15 years of age were classified as children. The baseline data recorded in the monitoring system are limited to the percentage of children with a baseline CD4 percentage <15% and the percentage of children who were treatment-experienced. Collection of other baseline data recommended by the
<xref ref-type="bibr" rid="bib24">WHO (2006b)</xref>
, particularly age, weight, baseline CD4 count and viral load results, was not recorded. Children were regarded as treatment-experienced if they had previously been exposed to ART for more than 1 month. Children who were previously exposed to perinatal NVP and/or AZT were not included in the treatment-experienced group.</p>
<p>Patients are entered into the register on commencing ART, and clinical and laboratory information is updated at 6-monthly intervals. The ART registers are used to complete the provincial monthly and quarterly reports, with data in the reports aggregated at facility level. Treatment-experienced patients and patients transferred in or out of an ART site are excluded from follow-up analysis in the monitoring system. Completed reports are faxed or e-mailed to the HIV Directorate of the Provincial Department of Health where data are collated using Microsoft Excel software.</p>
<p>CD4 percentages are measured using the PanLeucogating method, a dual-colour, dual-platform, CD45-assisted flow cytometric method that is the standard method for determining CD4 count and percentage in HIV-infected children in South Africa (
<xref ref-type="bibr" rid="bib7">Glencross et al., 2002</xref>
). HIV RNA-PCR (viral load) was quantified using a commercial assay (NucleoSens; bioMérieux B.V., Boxtel, The Netherlands) by the National Health Laboratory Services. A viral load <400 copies/ml is regarded as suppressed or undetectable.</p>
<sec>
<label>2.1</label>
<title>Data analysis</title>
<p>Outcomes analysed in this paper include death, loss to follow-up, changes in CD4 count and viral load, and change to second-line ART. Aggregation of data at individual clinics precluded traditional cohort analysis, therefore simplified cohort analysis was conducted as endorsed by the
<xref ref-type="bibr" rid="bib24">WHO (2006b)</xref>
. This technique measures defined outcomes at 6-monthly intervals through a series of cross-sectional analyses. Descriptive analyses were performed using proportions/percentages with exact binomial confidence intervals. Comparative analysis between the groups of children receiving ART at level 1 institutions and those receiving ART at level 2 & 3 hospitals was done using cumulative percentages, 95% CI and Kaplan–Meier estimates using the
<italic>ctset</italic>
command. The effect of baseline variables, including CD4 percentage <15%, year of starting ART and geographical region, on cumulative death rates at 6, 12 and 18 months was calculated using Poisson longitudinal regression, which allows for the analysis of aggregated data. All analyses were completed using Stata version 8.0 (StataCorp LP, College Station, TX, USA).</p>
</sec>
</sec>
<sec>
<label>3</label>
<title>Results</title>
<sec>
<label>3.1</label>
<title>Baseline data</title>
<p>The study analysed data on 1741 children started on ART (85.6% of the total number on ART by the end of March 2006) at 39 clinics in the Western Cape who were captured by the monitoring system. As reflected in
<xref ref-type="fig" rid="tbl3">Table 3</xref>
<fig id="tbl3">
<label>Table 3</label>
<caption>
<p>Baseline characteristics of children on antiretroviral therapy (ART)</p>
</caption>
<graphic mimetype="image" xlink:href="102-9-905-tbl003.tif"></graphic>
</fig>
, there were 361 children (20.7%) treated at 20 PHC clinics, 236 children (13.6%) at 16 district hospitals and 1144 children (65.7%) at three level 2 & 3 hospitals. The table further shows the diminishing number of children on ART at increasing durations of treatment.</p>
<p>At the start of ART, 801 children (46.0%) had severe immunodeficiency, i.e. a CD4 percentage <15%. The highest percentage of children enrolling with a CD4 count <15% was at district hospitals (52.1%, 95% CI 45–58%) and the lowest was at PHC clinics (35.5%, 95% CI 31–41%); the percentage at level 2 & 3 facilities was 48.1% (95% CI 36–52%). A larger percentage of treatment-experienced children were managed at district hospitals (6%, 95% CI 3.2–9.8%) compared with PHC clinics (0%) and level 2 & 3 hospitals (1.4%, 95% CI 0.8–2.3%) (
<xref ref-type="fig" rid="tbl3">Table 3</xref>
). The cumulative percentage of children transferred out during the first 18 months of ART was 13.1% at level 2 & 3 facilities, 2.1% at district hospitals and 6.1% at PHC clinics.</p>
</sec>
<sec>
<label>3.2</label>
<title>Deaths and loss to follow-up</title>
<p>Kaplan–Meier analysis showed overall survival estimates decreasing from 0.91 (95% CI 0.89–0.92) at 6 months to 0.86 (95% CI 0.83–0.88) at 18 months of ART.</p>
<p>There was less attrition (death and loss to follow-up) of children at PHC clinics and district hospitals compared with level 2 & 3 hospitals; however, the 95% CIs of these estimates overlapped (
<xref ref-type="fig" rid="fig1">Figure 1</xref>
<fig id="fig1" position="float">
<label>Figure 1</label>
<caption>
<p>Kaplan–Meier survival estimates (95% CI) for children on antiretroviral therapy (ART). PHC: primary healthcare.</p>
</caption>
<graphic mimetype="image" xlink:href="102-9-905-fig001.jpg"></graphic>
</fig>
). Further analysis illustrated that the estimated cumulative death rates were lower at PHC clinics at 6 months and 12 months of ART compared with either district hospitals or level 2 & 3 hospitals at these durations of ART, with exclusive 95% CIs, whereas loss to follow-up rates were similar (
<xref ref-type="fig" rid="fig2">Figure 2</xref>
<fig id="fig2" position="float">
<label>Figure 2</label>
<caption>
<p>Cumulative percentage (95% CI) of children on antiretroviral therapy (ART) lost to follow-up over time. PHC: primary healthcare.</p>
</caption>
<graphic mimetype="image" xlink:href="102-9-905-fig002.jpg"></graphic>
</fig>
;
<xref ref-type="fig" rid="tbl4">Table 4</xref>
<fig id="tbl4">
<label>Table 4</label>
<caption>
<p>Cumulative percentage (95% CI) of death and loss to follow-up for children on antiretroviral therapy (ART)</p>
</caption>
<graphic mimetype="image" xlink:href="102-9-905-tbl004.tif"></graphic>
</fig>
).</p>
<p>Multivariate analysis was conducted to assess the impact of baseline characteristics on measured outcomes. Poisson longitudinal regression showed that when adjusted for baseline CD4 percentage and the year of starting ART, the incidence rate ratio (IRR) of death was lower at PHC clinics compared with level 2 & 3 hospitals at 6 months (IRR = 0.33;
<italic>P</italic>
< 0.001), 12 months (IRR = 0.39;
<italic>P</italic>
= 0.003) and 18 months (IRR = 0.38;
<italic>P</italic>
= 0.018) of ART. Poisson regression also showed an 8% increase in the IRR for death during the first 6 months of ART for every 10% increase in the percentage of children with baseline CD4 percentage <15% at a PHC clinic (
<italic>P</italic>
= 0.017). The year of starting ART did not impact on death rates at 6, 12 and 18 months.</p>
</sec>
<sec>
<label>3.3</label>
<title>Viral load suppression</title>
<p>The overall cumulative percentage of children with a suppressed viral load increased from 72.3% (95% CI 69.1–75.4%) at 6 months to 76.8% (95% CI 69.9–83.1%) at 18 months of ART (
<xref ref-type="fig" rid="fig3">Figure 3</xref>
<fig id="fig3" position="float">
<label>Figure 3</label>
<caption>
<p>Cumulative percentage (95% CI) of viral loads suppressed over time in children on antiretroviral therapy (ART). PHC: primary healthcare.</p>
</caption>
<graphic mimetype="image" xlink:href="102-9-905-fig003.jpg"></graphic>
</fig>
). Suppression rates were highest at district hospitals at 12 months and 18 months of ART and lowest at level 2 & 3 hospitals, however the 95% CIs of these estimates overlapped.</p>
</sec>
<sec>
<label>3.4</label>
<title>CD4 percentage changes</title>
<p>The overall cumulative percentage of children with a CD4 percentage >20% increased steadily from 6 months (60.6%, 95% CI 57.2–64.0%) to 18 months (96.8%, 95% CI 92.9–98.9%) of ART. Estimates of the cumulative percentage of children with CD4 percentage >20% at 6, 12 or 18 months were similar at all facility types, with overlapping 95% CIs (
<xref ref-type="fig" rid="fig4">Figure 4</xref>
<fig id="fig4" position="float">
<label>Figure 4</label>
<caption>
<p>Cumulative percentage (95% CI) of patients with a CD4 percentage >20% over time in children on antiretroviral therapy (ART). PHC: primary healthcare.</p>
</caption>
<graphic mimetype="image" xlink:href="102-9-905-fig004.jpg"></graphic>
</fig>
).</p>
</sec>
<sec>
<label>3.5</label>
<title>Progression to second-line ART</title>
<p>Overall, 2.37% of children were changed to second-line ART during the first 18 months. The cumulative percentage of children starting second-line ART in the first 18 months of ART was higher at level 2 & 3 hospitals (3.11%, 95% CI 1.15–6.64%) than at district hospitals (2.78%, 95% CI 0.07–14.5%). There were no reports of children commencing second-line therapy at PHC clinics during the study period.</p>
</sec>
</sec>
<sec>
<label>4</label>
<title>Discussion</title>
<p>The clinical and immunological outcomes of children managed at PHC clinics and district hospitals were comparable with those in specialist care. This is probably due to a combination of good standards of care, application of a uniform provincial paediatric ART protocol, and onsite and/or telephone support from level 2 & 3 hospitals through the provincial paediatric outreach programme.</p>
<p>The restricted number of baseline variables recorded in the monitoring system has limited the analysis of outcomes. However, the data did show that a large percentage of the children treated at all facility types were severely immunodeficient (CD4% <15%) at the start of ART. Differences in baseline characteristics not recorded by the provincial monitoring system (e.g. age, clinical disease severity using the WHO's clinical classification, absolute CD4 count and viral load) could have explained the divergent death rates recorded in the present study (
<xref ref-type="fig" rid="tbl4">Table 4</xref>
) (
<xref ref-type="bibr" rid="bib1">Arrivé et al., 2007</xref>
;
<xref ref-type="bibr" rid="bib5">Eley et al., 2006</xref>
).</p>
<p>The majority of patients in the present study were started on ART at level 2 & 3 hospitals. From the beginning of 2006 onwards, many stable children were referred to level 1 facilities for ongoing ART as part of an explicit triaging policy. Children with advanced HIV disease, severe opportunistic infections, serious HIV-related complications or drug toxicities are preferentially managed at level 2 & 3 hospitals.</p>
<p>Children with uncomplicated disease are increasingly being treated at level 1 facilities. Because follow-up data of interclinic transfers were not captured by the provincial monitoring system, a detailed analysis of patient movements between facility types was not completed.</p>
<p>Virological outcomes at the different facility types were commendable. Viral load suppression rates varied from 71.6% to 90.3% after 18 months of ART and were comparable with published outcomes. Results from well resourced countries or clinical trials have recorded virological suppression rates ranging from 63% to 87% (
<xref ref-type="bibr" rid="bib20">van Rossum et al., 2002</xref>
). Published audits from Africa have not consistently reported on virological outcomes. Where virological suppression rates were documented, they have generally been lower than in the present study (
<xref ref-type="bibr" rid="bib1">Arrivé et al., 2007</xref>
;
<xref ref-type="bibr" rid="bib5">Eley et al., 2006</xref>
;
<xref ref-type="bibr" rid="bib8">Marazzi et al., 2006</xref>
;
<xref ref-type="bibr" rid="bib9">Nyandiko et al., 2006</xref>
;
<xref ref-type="bibr" rid="bib10">O’Brien et al., 2006</xref>
;
<xref ref-type="bibr" rid="bib13">Reddi et al., 2007</xref>
;
<xref ref-type="bibr" rid="bib14">Rouet et al., 2006</xref>
;
<xref ref-type="bibr" rid="bib16">The Malawi Paediatric Antiretroviral Treatment Group, 2007</xref>
;
<xref ref-type="bibr" rid="bib21">Wamalwa et al., 2007</xref>
). Virological suppression is a surrogate indicator of quality of care. The present results suggest that high care standards were maintained throughout the provincial treatment network. Progressive immunological improvements further supported the consistency of treatment standards. Both viral load suppression and CD4 percentage change analyses did not account for missing data or patient attrition. Consequently, sample attrition due to death or loss to follow-up may have removed patients whose viral loads were not suppressed or whose CD4 percentages failed to increase, leading to a differential bias away from the null hypothesis when comparing facility types.</p>
<p>The percentage of children changing to second-line ART by 18 months remained <2.5%. Noticeably, no children were changed to second-line ART at PHC clinics. This is most likely as a result of children failing treatment or not tolerating their ART being referred for specialist care. The low rate of second-line switches was inconsistent with the unsuppressed viral load rate of 23.1% at 18 months and may relate to unclear criteria for switching from first- to second-line treatment. The national treatment criteria for changing ART focus on clinical and immunological parameters and provide very rudimentary virological guidelines. Thus, lengthy delays often precede the introduction of second-line ART. Rigorous review of the guidelines for changing to second-line ART should be undertaken to improve the response to an unsuppressed viral load (
<xref ref-type="bibr" rid="bib3">Department of Health of South Africa, 2005</xref>
).</p>
<p>Although validation techniques have been built into the provincial monitoring system, problems such as missing or incorrect data were encountered. Whilst the aggregate nature of the monitoring system is appropriate for programme monitoring, a clearer understanding of determinants of outcomes will require an analysis of carefully validated individual data from sentinel sites, a process currently underway in the province. Aggregation diminishes the utility of the data as direct attribution of risk of baseline information to outcomes cannot be made. Additionally, the validity, during analysis, of aggregated data is decreased due to increased variance and error terms. A further consideration is the inability to merge data from the monitoring system with data from other sources, e.g. laboratory data, which is recorded on an individual basis.</p>
<p>In conclusion, this study recorded favourable short-term outcomes in children treated within a public sector provincial ART programme, and vindicated the National Department of Health's primary health care approach to scaling-up paediatric ART.</p>
</sec>
<sec>
<title>Funding</title>
<p>None.</p>
</sec>
<sec>
<title>Conflicts of interest</title>
<p>None declared.</p>
</sec>
<sec>
<title>Ethical approval</title>
<p>The Research Ethics Committee of the University of Cape Town (Ref. 050/2006), dated 6 May 2006.</p>
</sec>
<sec>
<title>Authors’ contributions</title>
<p>All authors contributed to the conception of the study; AB, CW, MO and PB conceived and designed the monitoring system from which the data analysed in this paper were captured; CW and MO collected the data; BE, AB, CW, MO and PB analysed and interpreted the data. All authors contributed to drafting the article and critically appraising it, and read and approved the final version. PB and BE are guarantors of the paper.</p>
</sec>
</body>
<back>
<ack>
<title>Acknowledgements</title>
<p>The authors wish to acknowledge all the staff at the primary care clinics providing ART to these children as well as the specialist teams at secondary and tertiary facilities who are not only providing care for children at their own facilities but are supporting the service at the primary care level as well. Additionally, they would like to acknowledge staff working in the HIV Directorate, Provincial Government of the Western Cape, and the Infectious Disease and Epidemiology Institute at the University of Cape Town for their input in the initiation and maintenance of the ART monitoring system.</p>
</ack>
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<title>References</title>
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<title>Provision of antiretroviral therapy to children within the public sector of South Africa</title>
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<name type="personal" displayLabel="corresp">
<namePart type="given">Peter</namePart>
<namePart type="family">Bock</namePart>
<affiliation>School of Public Health and Family Medicine, University of Cape Town, Anzio Road, Observatory, Cape Town 7925, South Africa</affiliation>
<affiliation>Department of Health, Provincial Government of the Western Cape, 4 Dorp Street, Cape Town 7708, South Africa</affiliation>
<affiliation>E-mail: peter@arkonline.org</affiliation>
<affiliation>Corresponding author. Present address: 7 Hares Avenue, Woodstock 7925, Cape Town, South Africa. Tel.: +27 21 447 0822. E-mail address: peter@arkonline.org</affiliation>
<affiliation>E-mail: peter@arkonline.org</affiliation>
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</role>
</name>
<name type="personal">
<namePart type="given">Andrew</namePart>
<namePart type="family">Boulle</namePart>
<affiliation>School of Public Health and Family Medicine, University of Cape Town, Anzio Road, Observatory, Cape Town 7925, South Africa</affiliation>
<role>
<roleTerm type="text">author</roleTerm>
</role>
</name>
<name type="personal">
<namePart type="given">Catherine</namePart>
<namePart type="family">White</namePart>
<affiliation>Department of Health, Provincial Government of the Western Cape, 4 Dorp Street, Cape Town 7708, South Africa</affiliation>
<role>
<roleTerm type="text">author</roleTerm>
</role>
</name>
<name type="personal">
<namePart type="given">Meg</namePart>
<namePart type="family">Osler</namePart>
<affiliation>Department of Health, Provincial Government of the Western Cape, 4 Dorp Street, Cape Town 7708, South Africa</affiliation>
<role>
<roleTerm type="text">author</roleTerm>
</role>
</name>
<name type="personal">
<namePart type="given">Brian</namePart>
<namePart type="family">Eley</namePart>
<affiliation>Red Cross Children's Hospital and the School of Child and Adolescent Health, University of Cape Town, Rondebosch, Cape Town 7701, South Africa</affiliation>
<role>
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</role>
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<abstract>The South African Department of Health has embraced the primary health care approach in the provision of antiretroviral therapy (ART) to children. This paper compares clinical outcomes of children treated at primary healthcare clinics, district hospitals, and secondary and tertiary hospitals. A retrospective review of routine data captured by the provincial antiretroviral monitoring system was completed. Simplified cohort analysis was used to determine the cumulative incidence of baseline characteristics and outcomes. Data on 1741 children started at level 2 & 3, level 1 and primary healthcare clinic facilities between April 2004 and April 2006 were analysed. Kaplan–Meier survival estimates for these groups were 0.88 (95% CI 0.86–0.90), 0.94 (95% CI 0.89–0.97) and 0.94 (95% CI 0.89–0.96) at 12 months of ART, respectively, on intention-to-treat analysis. The overall cumulative proportion of children with a suppressed viral load was 73% (95% CI 69–77%) at 12 months of ART. There was no significant difference in viral load suppression rates between the three groups. This study confirms the feasibility of providing antiretrovirals at all levels of the healthcare service in the Western Cape. The higher death rates at level 2 & 3 facilities are most likely due to recruitment of sicker patients at this level.</abstract>
<subject lang="en">
<genre>Keywords</genre>
<topic>Antiretroviral therapy</topic>
<topic>Children</topic>
<topic>Primary health care</topic>
<topic>Monitoring</topic>
<topic>Outcome assessment</topic>
<topic>Africa</topic>
</subject>
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<date>2008</date>
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<caption>vol.</caption>
<number>102</number>
</detail>
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<caption>no.</caption>
<number>9</number>
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   |étape=   Corpus
   |type=    RBID
   |clé=     ISTEX:5ECF4C9DA91FB9212471FEEBDE04B0B31FFFAAE9
   |texte=   Provision of antiretroviral therapy to children within the public sector of South Africa
}}
Wicri

This area was generated with Dilib version V0.6.32.
Data generation: Mon Nov 13 19:31:10 2017. Site generation: Wed Mar 6 19:14:32 2024