1. Scaling up access to HIV treatment: comparing outcomes among children receiving treatment at mobile and hospital-based HIV clinics in rural Zambia Janneke H. van Dijk 1,2, William J. Moss 3, Pamela Sinywimaanzi 1, Francis Hamangaba 1, Catherine G. Sutcliffe 3 1 Macha Research Trust, Zambia 1,, Erasmus University Rotterdam, the Netherlands 2, Johns Hopkins University, USA 3 Travel time and distance are barriers to care for HIV- infected children in resource-poor settings Decentralization is one of the keys to scaling-up access to antiretroviral treatment (ART) Study design: Ongoing pediatric cohort study at Macha Hospital since 2007 Analysis Population: Outreach group and hospital group

2. Results Comparison before and after transfer to mobileoutreach clinic Cost of travel Lower transportation costs after transfer (p<0.0001 ) Quality of care reported to be the same by the majority, although reports of better waiting times but poorer counseling services and physical examinations by some in outreach group. Travel time After transfer travel time was significantly shorter (>25% travelled ≥5 hrs vs. 4.5% ≥ 5 hrs after transfer, p<0.0001), Fewer use of public transportation (>40% vs. 4.6% public transport use, before and after transfer respectively)

3. Results Comparison of children receiving ART at Macha hospital and at outreach clinics Mean CD4% since ART initiation for Macha Hospital and outreach groups Hospital (n=41)Outreach (n=68)P-value Median age (yr, IQR)4.9 (2.2, 9.4)2.9 (1.6, 7.5)0.07 Male Gender19 (46.3%)22 (53.7%)0.41 Death0 (0.0%)1 (1.5%)0.44 LTFU0 (0.0%)7 (10.3%)0.03

4. Conclusion: Children in outreach group less likely to achieve virologic suppression, potentially due to lower adherence Continuous emphasis on the importance of adherence is critical for the success of decentralized care 11 children, of which 10 in outreach group (18.2% vs. 3.5%; p=0.06), experienced virologic failure Median % of visits with good adherence was significantly lower in the outreach group (69.2% vs. 79.3%; p<0.05) P=0.02 Proportion of children with undetectable viral load over time