GOOD SHEPHERD HOSPITAL - SWAZILAND

A prospective evaluation of a community based antiretroviral treatment programme in a rural African setting.

While Antiretroviral treatment (ART) for HIV/AIDS patients in sub Saharan Africa has typically been delivered in hospitals and large specialist clinics, a COMDIS study set out to evaluate whether shifting treatment from hospitals to community based ART treatment in a rural African district could improve attendance rates and health, and contribute towards achieving the MDG of universal access to treatment for HIV/AIDS for all those who need it.

This study was carried out in Lubombo, a rural region of Swaziland, the country with the highest prevalence rate of HIV in the world. The control group continued their treatment in hospital, while the intervention group included those attending the hospital ART programme who fulfilled the inclusion criteria and were offered community clinic follow up as an alternative to hospital treatment.

Outcomes, including attendance and loss to follow-up rates, were equal for health centre follow-up care as compared to standard fully hospital ART care. The patient preference indicators were either equal or showed a preference for health centre care.

The study concluded that health centre, nurse led care, is as effective and safe as standard hospital follow-up care. Providing ART in the primary care setting reduces patient costs and achieves equal rates of attendance at scheduled appointments. It releases ART clinic time to enrolled more patients on ART, and so contribute to achieving universal access.

Policy makers should consider the transfer of follow-up ART care services from overloaded hospital to community settings for the benefit of both patients and staff. Health managers will need to address staffing and resources at the primary care level to support the process of adding ART care while maintaining existing PHC services. Further experience and study is required to inform how to increase HIV testing in health centres and ensure early initiation of ART to all in need.