Search

Objective To determine the incidence of loss to follow-up in a treatment programme for people living with human immunodeficiency virus (HIV) infection in Kenya and to investigate how loss to follow-up is affected by gender. Methods Between November 2001 and November 2007, 50 275 HIV-positive individuals aged > 14 years (69% female; median age: 36.2 years) were enrolled in the study. An individual was lost to follow-up when absent from the HIV treatment clinic for > 3 months if on combination antiretroviral therapy (cART) or for > 6 months if not. The incidence of loss to follow-up was calculated using Kaplan-Meier methods anal factors associated with loss to follow-up were identified by logistic and Cox multivariate regression analysis. Findings Overall, 8% of individuals attended no follow-up visits, and 54% of them were lost to follow-up. The overall incidence of loss to follow-up was 25.1 per. 100 person-years. Among the 92% who attended at least one follow-up visit, the incidence of loss to follow-up before and after starting CART was 27.2 and 14.0 per 100 person- years, respectively. Baseline factors associated with loss to follow-up included younger age, a long travel time to the clinic, patient disclosure of positive HIV status, high CD4+ lymphocyte count, advanced-stage HIV disease, and rural clinic location. Men were at an increased risk overall and before and after starting cART. Conclusion The risk of being lost to follow-up was high, particularly before starting cART. Men were more likely to become lost to follow-up, even after adjusting for baseline sociodemographic and clinical characteristics. Interventions designed for men and women separately could improve retention. Objectif Determiner l'incidence de perte de suivi dans un programme de traitement pour les personnes vivant avec l'infection par le virus de l'immunodeficience humaine (VIH) au Kenya, et investiguer comment la perte de suivi est influencee par le sexe. Methodes Entre novembre 2001 et novembre 2007, 50 275 individus seropositifs d'age [is greater than or equal to] 14 ans (69% de sexe feminin; age median: 36,2 ans) ont participe a l'etude. Le suivi a ete perdu lorsque les individus ont ete absents de la clinique de traitement du VIH pendant > 3 mois lorsqu'ils etaient sous combinaison therapeutique antiretrovirale (TARV), et pendant > 6 mois dans le cas contraire. L'incidence de perte du suivi a ete calculee au moyen des methodes Kaplan-Meier, et les facteurs associes a la perte du suivi ont ete identifies par la regression logistique et l'analyse multivariable par regression du modele de Cox. Resultats Globalement, 8% des individus ne se sont jamais presentes a unevisite de suivi, et 54% d'entre eux ont perdu le suivi. L'incidence totale de perte du suivi etait de 25,1 par 100 personnes-annees. Parmi les 92% qui ont assiste a une visite de suivi au moins, l'incidence de perte du suivi avant et apres le debut du TARV a ete de 27,2 et 14,0 par 100 personnes-annees, respectivement. Parmi les facteurs de la ligne de base associes a la perte du suivi, ont ete constates le jeune age, la longueur du temps de trajet pour se rendre a la clinique, la revelation de l'etat VIH positif du patient, un nombre eleve de lymphocytes CD4+, un stade avance de la maladie a VIH et la ruralite de la clinique. Les hommes ont presente un risque plus eleve en general et ce, avant et apres le debut du TARV. Conclusion Le risque de perte du suivi a ete eleve, particulierement avant le debut du TARV. Les hommes ont ete plus enclins a perdre le suivi, meme apres ajustement pour base sociodemographique et caracteristiques cliniques. Des interventions concues separement pour les hommes et les femmes pourraient ameliorer la retention. Objetivo Determinar la incidencia de bajas en el seguimiento de un programa terapeutico de personas portadoras del virus de la inmunodeficiencia humana (VIH) en Kenya, e investigar si el sexo de dichas personas influye en las bajas en el seguimiento. Metodos Entre noviembre de 2001 y noviembre de 2007 se inscribieron en el estudio 50 275 personas VIH-positivas de mas de 14 anos de edad (69% mujeres; edad media: 36,2 anos). Se considero Una baja en el seguimiento cuando la persona se ausento de la clinica de tratamiento del VIH durante mas de tres meses si estaba en tratamiento antirretroviral combinado (TARC) o, en el caso contrario, durante mas de seis meses. La incidencia de bajas en el seguimiento se ha calculado utilizando los metodos de Kaplan-Meier, y los factores asociados con las bajas en el seguimiento se han identificado mediante un analisis de regresion logistica y de regresion multifactorial de Cox. Resultados En terminos generales, el 8% de las personas no acudieron a las visitas de seguimiento, de las que el 54% se consideraron como bajas en el seguimiento. La incidencia total de bajas en el seguimiento fue de 25,1 por 100 anos-persona. Dei 92% que acudio al menos a una visita de seguimiento, la incidencia de baja en el seguimiento, antes y despues de comenzar el TARC fue de 27,2 y 14,0 por 100 anos persona, respectivamente. Los factores iniciales asociados a la baja en el seguimiento incluyeron: la juventud, la lejania de la clinica, la revelacion dei paciente de su estado de VIH-positivo, el recuento linfocitico CD4+ elevado, enfermedades debidas al VIH en fase avanzada y la ubicacion de la clinica rural. El riesgo general en hombres fue elevado, antes y despues de iniciar el TARC. Conclusion El riesgo de baja en el seguimiento dei paciente fue elevado, sobre todo antes de iniciar el TARC. Hubo una tendencia de mas bajas en el seguimiento entre los hombres, aun despues dei ajuste de las caracteristicas sociodemograficas y clinicas iniciales. Las intervenciones especificas e individuales para hombres y mujeres podrian mejorar la permanencia en el programa., Introduction Approximately 33 million people worldwide are living with human immunodeficiency virus (HIV) infection or acquired immunodeficiency syndrome (AIDS), and the majority are in sub-Saharan Africa. (1) The use of [...]

Background: A major obstacle facing many lower‐income countries in establishing and maintaining HIV treatment programmes is the scarcity of trained health care providers. To address this shortage, the World Health Organization has recommend task shifting to HIV‐infected peers. Methods: We designed a model of HIV care that utilizes HIV‐infected patients, community care coordinators (CCCs), to care for their clinically stable peers with the assistance of preprogrammed personal digital assistants (PDAs). Rather than presenting for the standard of care, monthly clinic visits, in this model, patients were seen every three months in clinics and monthly by their CCCs in the community during the interim two months. This study was conducted in Kosirai Division, western Kenya, where eight of the 24 sub‐locations (defined geographic areas) within the division were randomly assigned to the intervention with the remainder used as controls. Prior to entering the field, CCCs underwent intensive didactic training and mentoring related to the assessment and support of HIV patients, as well as the use of PDAs. PDAs were programmed with specific questions and to issue alerts if responses fell outside of pre‐established parameters. CCCs were regularly evaluated in six performance areas. An impressionistic analysis on the transcripts from the monthly group meetings that formed the basis of the continuous feedback and quality improvement programme was used to assess this model. Results: All eight of the assigned CCCs successfully passed their training and mentoring, entered the field and remained active for the two years of the study. On evaluation of the CCCs, 89% of their summary scores were documented as superior during Year 1 and 94% as superior during Year 2. Six themes emerged from the impressionistic analysis in Year 1: confidentiality and “community” disclosure; roles and responsibilities; logistics; clinical care partnership; antiretroviral adherence; and PDA issues. At the end of the trial, of those patients not lost to follow up, 64% (56 of 87) in the intervention and 52% (58 of 103) in the control group were willing to continue in the programme (p = 0.26). Conclusion: We found that an antiretroviral treatment delivery model that shifted patient monitoring and antiretroviral dispensing tasks into the community by HIV‐infected patients was both acceptable and feasible. Trial registration: ClinicalTrials.gov ID NCT00371540, Introduction Two‐thirds of the approximately 33 million HIV‐infected people globally reside in the resource‐constrained countries of sub‐Saharan Africa, where more than 50% of the population lives in rural areas [1,2]. [...]

A study was conducted to determine outcome differences between orphaned and non-orphaned children receiving antiretroviral therapy (ART). Orphan status was not associated with worse short-term outcomes but might be a factor for long-term therapy response and HIV-positive children did not overcome developmental lags present before initiation of therapy, suggesting that ART might be only partially able to reverse significant developmental lags in the HIV-positive pediatric population.

Background and aims: Culturally relevant and feasible interventions are needed to address limited professional resources in sub‐Saharan Africa for behaviorally treating the dual epidemics of HIV and alcohol use disorder. This study tested the efficacy of a cognitive–behavioral therapy (CBT) intervention to reduce alcohol use among HIV‐infected outpatients in Eldoret, Kenya. Design Randomized clinical trial. Setting: A large HIV outpatient clinic in Eldoret, Kenya, affiliated with the Academic Model Providing Access to Healthcare collaboration. Participants: A total of 614 HIV‐infected outpatients [312 CBT; 302 healthy life‐styles (HL); 48.5% male; mean age: 38.9 years; mean education 7.7 years] who reported a minimum of hazardous or binge drinking. Intervention and comparator: A culturally adapted six‐session gender‐stratified group CBT intervention compared with HL education, each delivered by paraprofessionals over six weekly 90‐minute sessions with a 9‐month follow‐up. Measurements Primary outcome measures were percentage of drinking days (PDD) and mean drinks per drinking day (DDD) computed from retrospective daily number of drinks data obtained by use of the time‐line follow‐back from baseline to 9 months post‐intervention. Exploratory analyses examined unprotected sex and number of partners. Findings Median attendance was six sessions across condition. Retention at 9 months post‐intervention was high and similar by condition: CBT 86% and HL 83%. PDD and DDD marginal means were significantly lower in CBT than HL at all three study phases. Maintenance period, PDD – CBT = 3.64 (0.696), HL = 5.72 (0.71), mean difference 2.08, 95% confidence interval (CI) = 0.13 – 4.04; DDD – CBT = 0.66 (0.96), HL = 0.98 (0.098), mean difference = 0.31, 95% CI = 0.05 – 0.58. Risky sex decreased over time in both conditions, with a temporary effect for CBT at the 1‐month follow‐up. Conclusions: A cognitive–behavioral therapy intervention was more efficacious than healthy lifestyles education in reducing alcohol use among HIV‐infected Kenyan outpatient drinkers. [ABSTRACT FROM AUTHOR]

Objective: Efficient, effective health care requires rapid availability of patient information. We designed, implemented, and assessed the impact of a primary care electronic medical record (EMR) in three rural Kenyan health centers.Method: Local clinicians identified data required for primary care and public health reporting. We designed paper encounter forms to capture these data in adult medicine, pediatric, and antenatal clinics. Encounter form data were hand-entered into a new primary care module in an existing EMR serving onsite clinics serving patients infected with the human immunodeficiency virus (HIV). Before subsequent visits, Summary Reports were printed containing selected patient data with reminders for needed HIV care. We assessed effects on patient flow and provider work with time-motion studies before implementation and two years later, and we surveyed providers' satisfaction with the EMR.Results: Between September 2008 and December 2011, 72 635 primary care patients were registered and 114 480 encounter forms were completed. During 2011, 32 193 unique patients visited primary care clinics, and encounter forms were completed for all visits. Of 1031 (3.2%) who were HIV-infected, 85% received HIV care. Patient clinic time increased from 37 to 81 min/visit after EMR implementation in one health center and 56 to 106 min/visit in the other. However, outpatient visits to both health centers increased by 85%. Three-quarters of increased time was spent waiting. Despite nearly doubling visits, there was no change in clinical officers' work patterns, but the nurses' and the clerks' patient care time decreased after EMR implementation. Providers were generally satisfied with the EMR but desired additional training.Conclusions: We successfully implemented a primary care EMR in three rural Kenyan health centers. Patient waiting time was dramatically lengthened while the nurses' and the clerks' patient care time decreased. Long-term use of EMRs in such settings will require changes in culture and workflow. [ABSTRACT FROM AUTHOR]

Providing high-quality HIV/AIDS care requires high-quality, accessible data on individual patients and visits. These data can also drive strategic decision-making by health systems, national programs, and funding agencies. One major obstacle to HIV/AIDS care in developing countries is lack of electronic medical record systems (EMRs) to collect, manage, and report clinical data. In 2001, we implemented a simple primary care EMR at a rural health centre in western Kenya. This EMR evolved into a comprehensive, scalable system serving 19 urban and rural health centres. To date, the AMPATH Medical Record System contains 10 million observations from 400,000 visit records on 45,000 patients. Critical components include paper encounter forms for adults and children, technicians entering/managing data, and modules for patient registration, scheduling, encounters, clinical observations, setting user privileges, and a concept dictionary. Key outputs include patient summaries, care reminders, and reports for program management, operating ancillary services (e.g., tracing patients who fail to return for appointments), strategic planning (e.g., hiring health care providers and staff), reports to national AIDS programs and funding agencies, and research. [ABSTRACT FROM AUTHOR]

Providing high-quality HIV/AIDS care requires high-quality, accessible data on individual patients and visits. These data can also drive strategic decision-making by health systems, national programs, and funding agencies. One major obstacle to HIV/AIDS care in developing countries is lack of electronic medical record systems (EMRs) to collect, manage, and report clinical data. In 2001, we implemented a simple primary care EMR at a rural health centre in western Kenya. This EMR evolved into a comprehensive, scalable system serving 19 urban and rural health centres. To date, the AMPATH Medical Record System contains 10 million observations from 400,000 visit records on 45,000 patients. Critical components include paper encounter forms for adults and children, technicians entering/managing data, and modules for patient registration, scheduling, encounters, clinical observations, setting user privileges, and a concept dictionary. Key outputs include patient summaries, care reminders, and reports for program management, operating ancillary services (e.g., tracing patients who fail to return for appointments), strategic planning (e.g., hiring health care providers and staff), reports to national AIDS programs and funding agencies, and research.