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Task Shifting for the Delivery of Pediatric Antiretroviral Treatment: A Systematic Review

Penazzato, Martina MD, MSc, PhD*; Davies, Mary-Ann MD, MPH; Apollo, Tsitsi MBChB, MPH; Negussie, Eyerusalem MD, MPH*; Ford, Nathan MPH, PhD*

JAIDS Journal of Acquired Immune Deficiency Syndromes: April 1st, 2014 - Volume 65 - Issue 4 - p 414–422
doi: 10.1097/QAI.0000000000000024
Clinical Science

Background: Pediatric antiretroviral treatment coverage in resource-limited settings continues to lag behind adults. Task shifting is an effective approach broadly used for adults, which some countries have also adopted for children, but implementation is limited by lack of confidence and skills among nonspecialist staff.

Methods: A systematic review was conducted by combining key terms for task shifting, antiretroviral therapy (ART), and children. Five databases and two conferences were searched from inception till August 01, 2013.

Results: Eight observational studies provided outcome data for 11,828 children who received ART from nonphysician providers across 10 countries in sub-Saharan Africa. The cumulative pooled proportion of deaths was 3.2% [95% confidence interval (CI): 2.0 to 4.5] at 6 months, 4.6% (95% CI: 2.1 to 7.1) at 12 months, 6.2% (95% CI: 3.7 to 8.8) at 24 months, and 5.9% (95% CI: 3.5 to 8.3) at 36 months. Mortality and loss to follow-up in task-shifting programs were comparable to those reported by programs providing doctor- or specialist-led care.

Conclusions: Our review suggests that task shifting of ART care can result in outcomes comparable to routine physician care, and this approach should be considered as part of a strategy to scale-up pediatric treatment. Specialist care will remain important for management of sick patients and complicated cases. Further qualitative research is needed to inform optimal implementation of task shifting for pediatric patients.

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*HIV/AIDS Department, World Health Organization, Geneva, Switzerland;

Centre for Infectious Disease Epidemiology and Research, University of Cape Town, Cape Town, South Africa; and

HIV and AIDS Department, Ministry of Health and Social Welfare, Harare, Zimbabwe.

Correspondence to: Nathan Ford, MPH, PhD, HIV/AIDS Department, World Health Organization, Geneva, Switzerland (e-mail:

Supported by partial funding by a grant from the Bill and Melinda Gates Foundation.

The authors have no conflicts of interest to disclose.

The authors N.F. and M.P. conceived the study, conducted the literature review, analyzed the data, and drafted the article. M.D. contributed to resolve discrepancies and provided direct input in the comparative analyses. M.D., T.A., and E.N. have contributed to the writing of the article. All authors have read and approved the final article.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (

Received August 28, 2013

Accepted October 01, 2013

© 2014 by Lippincott Williams & Wilkins