What affects patient outcomes? A retrospective cross-country analysis of facility performance in sub-Saharan Africa

Abstract Background The life-saving benefits of antiretroviral therapy (ART) for HIV-infected patients have been well established. However, there continues to be much debate on how best to deliver ART care. In this study, we seek to answer part of this question by examining facility-level determinants of patient outcome. Methods We examined a nationally representative sample of health facilities providing ART in Kenya, Uganda, and Zambia. Facility-level data were collected through an extensive survey that gathered information ranging from finances and management, to services and outputs. Patient-level information was collected from a random sample of charts of patients who were receiving or had received ART. All adult patients who had been on ART between 6 and 60 months at the time of data collection, regardless of outcome, were eligible for inclusion. Descriptive statistics examining patient-level trends at ART initiation over time, as well as logistic regression and survival analyses to assess for facility-level effects on outcome, were performed. Findings We collected data from more than 30 000 patient charts across 138 facilities. Initial findings suggest that patient outcomes are largely driven by patient-level characteristics at the time of ART initiation. Initial CD4 cell count, body-mass index, and WHO clinical staging were all predictive of 12-month and 24-month retention. Conversely, we found no consistent 12-month or 24-month retention trend with regard to facility-level ART programme characteristics such as facility type (hospital vs health clinic), location (urban vs rural), management (private vs public), funding source, number of years the facility has been in operation, leadership type (physician vs nurse), or existence of outreach programmes. Interpretation These findings further support the critical need to expand ART programmes to initiate patients early in the disease process. They also suggest that many aspects of ART care could potentially be carried out safely and effectively at smaller, lower complexity facilities with less-specialised personnel. Funding Bill & Melinda Gates Foundation.