decentralization of hiv care and treatment services in central province, kenya:
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Decentralization of HIV care and treatment services in Central Province, Kenya: Adult patient characteristics and outcomes. Presenting author: William Reidy , PhD Reidy W, Hawken M, Wang C, Koech E, Elul B, and Abrams EJ - PowerPoint PPT PresentationTRANSCRIPT
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Decentralization of HIV care and treatment services
in Central Province, Kenya: Adult patient characteristics and
outcomesPresenting author: William Reidy, PhD
Reidy W, Hawken M, Wang C, Koech E, Elul B, and Abrams EJ
for the Identifying Optimal Models of HIV Care in Africa: Kenya Consortium
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Background: Kenya
• Population: 38.6 million
• Adult HIV prevalence: 6.2%
• Living with HIV: 1.6 million
• Estimated annual number of newly infected: 100,000
• Number died of AIDS-related causes in 2011: 49,126
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Background: Decentralization of HIV care in Kenya
• HIV care/ART in Kenya was provided in a small number of secondary health facilities (HF): – District, sub-district, provincial, or
teaching/national referral hospitals• Beginning in 2004, started scaling up HIV
clinics at smaller, primary HF:– Health centers and dispensaries
• Performance of primary HF during scale-up is not well-established
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Objective• To compare the performance of
primary and secondary HF in Central Province, Kenya during a period of scale-up: –Patient volume–Patient and facility characteristics–Quality of care–Patient retention
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Population and data sources• 37 of 52 government health facilities in
Central Province supported by ICAP at Columbia University via PEPFAR funding – 15 secondary and 22 primary HF
• Included patients enrolled between 2006-10 (N= 26,690)
• Data sources:– HIV care/ART data from patient-level databases
maintained by facility staff– Annual facility survey conducted by ICAP
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Key variables and outcomes (1)
• Patient volume– Number of patients enrolled in HIV
care, by year• Patient characteristics
– Gender, age, WHO stage, CD4 count at enrollment and ART initiation
• Facility characteristics– Rural/non-rural, nurse ART provision,
CD4 machine on-site
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Key variables and outcomes (2)
• Quality of care– Assessment of ART eligibility
(CD4/WHO), prompt ART initiation• Patient retention
1. Death: Recorded as dead in facility database
2. Loss to follow-up: Not dead, not transferred out, and not attending clinic for >6 months for patients on ART, or >12 month for pre-ART patients
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Analytic Methods• Descriptive statistics• Kaplan-Meier survival curves• Competing risks regression (pre-
ART) and Cox proportional hazards regression (ART) Multivariate regression models
included: site type (primary vs. secondary HF), WHO stage, CD4 count, age group, gender, year of patient enrollment in care or ART initiation
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Results
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Patient volume
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Enrollment in HIV care and treatment at primary and secondary HF
2006 2007 2008 2009 20100
1000
2000
3000
4000
5000
6000
7000
0
5
10
15
20
25
Primary HF Secondary HF
Num
ber o
f pati
ents
# of
faci
lities
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Enrollment in HIV care and treatment at primary and secondary HF
2006 2007 2008 2009 20100
1000
2000
3000
4000
5000
6000
7000
0
5
10
15
20
25
Primary HFs Secondary HF
Num
ber o
f pati
ents
# of
faci
lities
# Primary HF
# Secondary HF
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Facility characteristics
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Clinic location, nurse ART provision, and presence of CD4
machine on-site
Loca
ted in
rura
l are
a
Nurse pr
ovisi
on of
ART
CD4 mac
hine o
n site
0%20%40%60%80%
100%
Primary Health Facilities Secondary Health Facilities
% o
f fac
iliti
es
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Patient characteristics
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Characteristics at enrollment in HIV care
Primary HF Secondary HF(n=3,881) (n=22,809)
Female 72% 69%Age group
15-20 2% 2%20-30 20% 23%30-40 43% 42%40+ 35% 34%
CD4 count 40% missing 41% missing<100 25% 31%
100-200 22% 22%200-350 22% 20%
350+ 31% 27%WHO stage 11% missing 24% missing
I/II 69% 60%III/IV 31% 40%
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Point of entry to HIV care
Primary HF
Secondary HF
(n=3,881)
(n=22,809)
Transferred in 20% 12%VCT 19% 29%PMTCT 12% 9%TB/HIV 5% 6%PITC 3% 6%Unknown/other 41% 34%
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Characteristics of patients starting ART
Primary HF Secondary HF
(n=2,391) (n=13,486)CD4 value at ART initiation
19% missing
18% missing
<100 32% 38%100-200 30% 30%200-350 32% 26%
350+ 7% 5%WHO stage at ART initiation
13% missing
18% missing
I/II 52% 52%III/IV 48% 48%
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Quality of care: ART eligibility assessment
and prompt initiation
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At enrollment in HIV care
Within first 3 months of HIV
care
Within first 6 months of HIV
care
0%
20%
40%
60%
80%
Percent with ART eligibility assessed by CD4 or WHO
stage
Primary HF Secondary HF
% o
f pa
tien
ts
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0%
40%
80%
Percent of patients ART-eli-gible at enrollment who
started ART
Primary HF Secondary HF
% o
f pa
tien
ts
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Patient retention: Death and loss to follow-up
(LTF)
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Death following enrollment in HIV care (pre-ART)
Adjusted SHR=1.2995% CI: (0.91-1.84)
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Adjusted SHR=0.77 95% CI: (0.62-0.97)
LTF following enrollment in HIV care (pre-ART)
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Death following ART initiation
Adjusted HR=0.94 95% CI: (0.67-1.32)
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LTF following ART initiation
Adjusted HR=0.67 95% CI: (0.27-1.65)
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Adjusted S/HR of non-retention in Primary vs. Secondary HF
All patients
Adjusted S/HR* 95% CI
Pre-ART Death 1.29 0.91-1.84
LTF 0.77 0.62-0.97
ART Death 0.94 0.67-1.32
LTF 0.67 0.27-1.65*Reference category: Secondary HF. Models control for WHO stage,
CD4 count, age group, gender, year of patient enrollment in care or ART initiation
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Adjusted S/HR of non-retention in Primary vs. Secondary HF
Sensitivity analysis excluding transfer-in patients
All patientsExcluding transfer-in patients
Adjusted S/HR* 95% CI Adjuste
d S/HR* 95% CI
Pre-ART Death 1.29 0.91-1.84 1.32 0.92-
1.89LTF 0.77 0.62-
0.97 0.84 0.66-1.07
ART Death 0.94 0.67-1.32 0.94 0.65-
1.35LTF 0.67 0.27-
1.65 0.72 0.28-1.82
*Reference category: Secondary HF. Models control for WHO stage, CD4 count, age group, gender, year of patient enrollment in care or ART initiation
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Summary• Patient enrollment at primary HF
increased dramatically during the period
• Patients enrolling in primary HF were somewhat healthier by WHO stage, CD4 count
• Quality of patient care and retention were comparable at primary and secondary HF – Among pre-ART patients, the rate of
LTF was lower at primary than at secondary facilities
• Primary HF have performed well within the context of decentralization in Central Province, Kenya
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Acknowledgements• Kenya Ministry of Health• Government staff at the 37 facilities• ICAP staff in Kenya and in New York
– Dr. Muhsin Sheriff (Kenya), Mansi Agarwal (NY)
• US Centers for Disease Control and Prevention
• The President’s Emergency Plan for AIDS Relief
• This research was supported by PEPFAR through the CDC under the terms of Cooperative Agreement Number 5U62PS223540 and 5U2GPS001537