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Health service delivery models for the provision of antiretroviral therapy in sub‐Saharan Africa: a systematic review
Author(s) -
Lazarus Jeffrey V.,
SafreedHarmon Kelly,
Nicholson Joey,
Jaffar Shabbar
Publication year - 2014
Publication title -
tropical medicine and international health
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 1.056
H-Index - 114
eISSN - 1365-3156
pISSN - 1360-2276
DOI - 10.1111/tmi.12366
Subject(s) - service delivery framework , medicine , antiretroviral therapy , systematic review , medline , service (business) , health care , developing country , family medicine , human immunodeficiency virus (hiv) , nursing , business , viral load , political science , economic growth , marketing , economics , law
Objectives In response to the lack of evidence‐based guidance for how to continue scaling up antiretroviral therapy ( ART ) in ways that make optimal use of limited resources, to assess comparative studies of ART service delivery models implemented in sub‐Saharan Africa. Methods A systematic literature search and analysis of studies that compared two or more methods of ART service delivery using either CD 4 count or viral load as a primary outcome. Results Most studies identified in this review were small and non‐randomised, with low statistical power. Four of the 30 articles identified by this review conclude that nurse management of ART compares favourably to physician management. Seven provide evidence of the viability of managing ART at lower levels within the health system, and one indicates that vertical and integrated ART programmes can achieve similar outcomes. Five articles show that community/home‐based ART management can be as effective as facility‐based ART management. Five of seven articles investigating community support link it to better clinical outcomes. The results of four studies suggest that directly observed therapy may not be an important component of ART programmes. Conclusions Given that the scale‐up of antiretroviral therapy represents the most sweeping change in healthcare delivery in sub‐Saharan Africa in recent years, it is surprising to not find more evidence from comparative studies to inform implementation strategies. The studies reported on a wide range of service delivery models, making it difficult to draw conclusions about some models. The strongest evidence was related to the feasibility of decentralisation and task‐shifting, both of which appear to be effective strategies.