Decentralised paediatric HIV care in Ethiopia: a comparison between outcomes of patients managed in health centres and in a hospital clinic

BACKGROUND: In order to increase access to antiretroviral therapy (ART) in HIV-infected children, paediatric HIV care has been introduced in health centres in Ethiopia, where patients are managed by health professionals with limited training. OBJECTIVE: To compare outcomes of paediatric HIV care in hospital and health centre clinics and to determine risk factors for death and loss to follow-up (LTFU). DESIGN: Retrospective comparison of patient characteristics and outcomes among children managed in a public hospital and all five public health centres in the uptake area. RESULTS: Among 1,960 patients (health centres 572, hospital clinic 1,388), 34% were lost to follow-up, 2% died, 14% were transferred out, and 46% remained in care. Children initiating ART in the hospital clinic had lower median CD4 cell counts (age <1 year: 575 vs. 1,183 cells/mm(3), p=0.024; age 1–5 years: 370 vs. 598 cells/mm(3), p<0.001; age >5 years: 186 vs. 259 cells/mm(3), p<0.001), and a higher proportion were <1 year of age (22% vs. 15%, p=0.025). ART initiation rates and retention in care were similar between children managed in health centres and in the hospital clinic (36% vs. 37% and 47% vs. 46%, respectively). Among patients starting ART, mortality was associated with age <1 year [hazard ratio (HR) 12.0; 95% confidence interval (CI): 3.5, 41]. LTFU was associated with CD4 cell counts <350 cells/mm(3) (HR 1.8; 95% CI: 1.2, 3.0), weight-for-age z-scores below −4 (HR 2.8; 95% CI: 1.4, 5.6), and age <5 years (1–5 years: HR 1.6; 95% CI: 1.0, 2.5; <1 year: HR 3.3; 95% CI: 1.6, 6.6). CONCLUSIONS: Outcomes of HIV care were similar for Ethiopian children managed in a hospital clinic or in health centres. However, patients treated at the hospital clinic had characteristics of more advanced disease. Rates of LTFU were high in both types of health facility.