Issues: Concurrent sexual partnerships establish network connectivity in populations with low rat... more Issues: Concurrent sexual partnerships establish network connectivity in populations with low rates of partner acquisition. This can accelerate the spread of HIV infection. National and international health and development agencies working in highly affected African countries have called for interventions to reduce multiple and concurrent partnerships (MCP). Description: The Know Your Network intervention (KYN) uses interactive exercises and a PDA survey of participants' sexual behavior to illustrate the impact of MCP. Researchers and study participants in western Kenyan communities with high HIV prevalence collaborated to develop KYN, and this project conducts formative research and elicits community and health care worker feedback to a trial run of KYN. Methods: We will use mabaraza (community meetings) and focus group discussions (FGD) to engage village leaders and community members in this project. Mabaraza with chiefs and elders will take place in April 2010. We will use qu...
Studies in health technology and informatics, 2007
Providing high-quality HIV/AIDS care requires high-quality, accessible data on individual patient... more 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, a...
Mosoriot Health Center is a rural primary care facility situated on the outskirts of Eldoret, Ken... more Mosoriot Health Center is a rural primary care facility situated on the outskirts of Eldoret, Kenya in sub-Saharan Africa. The region is characterised by widespread poverty and a very poor technology infrastructure. Many houses do not have electricity, telephones or tap water. The health center does have electricity and tap water. In a collaborative project between Indiana University and the Moi University Faculty of Health Sciences (MUFHS), we designed a core electronic medical record system within the Mosoriot Health Center, with the intention of improving the quality of health data collection and, subsequently, patient care. The electronic medical record system will also be used to link clinical data from the health center to information collected from the public health surveys performed by medical students participating in the public health research programs of Moi University. This paper describes the processes involved in the development of the computer-based Mosoriot medical record system (MMRS) up to the point of implementation. It particularly focuses on the decisions and trade-offs that must be made when introducing this technology into an established health care system in a developing country.
Studies in health technology and informatics, 2010
Efficient use of health care resources in low-income countries by providers and local and nationa... more Efficient use of health care resources in low-income countries by providers and local and national managers requires timely access to patient data. To implement electronic health records (EHRs) in HIV clinics in Kenya, Tanzania, and Uganda. We initially developed and implemented an EHR in Kenya through a mature academic partnership. The EHR was then implemented in six HIV clinics in Tanzania and Uganda in collaboration with their National AIDS Control Programmes. All implementations were successful, but the system's use and sustainability varied depending on who controlled clinic funding. Successful EHR use and sustainability were enhanced by local control of funds, academic partnerships (mainly by leveraging research funds), and in-country technology support.
SAHARA-J: Journal of Social Aspects of HIV/AIDS, 2009
Clinical programmes are typically evaluated on operational performance metrics of cost, quality a... more Clinical programmes are typically evaluated on operational performance metrics of cost, quality and outcomes. Measures of patient satisfaction are used to assess the experience of receiving care, but other perspectives, including those of staff and communities, are not often sought or used to assess and improve programmes. For strategic planning, the Kenyan HIV/AIDS programme AMPATH (Academic Model Providing Access to Healthcare) sought to evaluate its performance in 2006. The method used for this evaluation was termed 'triangulation, ' because it used information from three different sources -patients, communities, and programme staff. From January to August 2006, Indiana University external evaluators and AMPATH staff gathered information on strengths, weaknesses and suggestions for improvement of AMPATH. Activities included in-depth key-informant semi-structured interviews of 26 AMPATH clinical and support staff, 56 patients at eight clinic sites, and seven village health dialogues (mabaraza) at five sublocations within the AMPATH catchment area. Data sources included field notes and transcripts of translated audio recordings, which were subjected to qualitative content analysis. Eighteen recommendations for programme improvement emerged, including ten from all three respondent perspectives. Three recommendations were cited by patients and in mabaraza, but not by staff.
Jaids-journal of Acquired Immune Deficiency Syndromes, 2009
In 2001, HIV postexposure prophylaxis (PEP) was initiated in western Kenya. Design, implementatio... more In 2001, HIV postexposure prophylaxis (PEP) was initiated in western Kenya. Design, implementation, and evolution of the PEP program are described. Patient data were analyzed for reasons, time to initiation, and PEP outcome. Occupational PEP was initiated first followed by nonoccupational PEP (nPEP). Antiretroviral regimens were based upon national PEP guidelines, affordability and availability, and prevailing HIV prevalence. Emerging side effects data and cost improvements influenced regimen changes. Between November 2001 and December 2006, 446 patients sought PEP. Occupational exposure: 91 patients: 51 males; 72 accepted HIV testing; 48 of 52 source patients were HIV infected; median exposure-PEP time 3 hours (range: 0.3-96 hours). Of 72 HIV-negative patients receiving PEP, 3 discontinued, 69 completed, and 23 performed post-PEP HIV RNA polymerase chain reaction (all negative). Eleven follow-up HIV enzyme-linked immunosorbent assay tests have all turned negative. Nonoccupational exposure: 355 patients; 285 females; 90 children; 300 accepted HIV testing; median exposure-nPEP time 19 hours (range: 1-672 hours). Of 296 HIV-negative patients on nPEP, 1 died, 15 discontinued, 104 are on record having completed PEP, and 129 returned for 6-week HIV RNA polymerase chain reaction (1 patient tested positive). Eighty-seven follow-up HIV enzyme-linked immunosorbent assay tests have all turned negative. It is feasible to provide PEP and nPEP in resource-constrained settings.
Traditional cultural practices and sexual rituals have an important role in the life and structur... more Traditional cultural practices and sexual rituals have an important role in the life and structure of tribal groups within Kenya. These cultural practices and rituals also play a significant role in the spread of HIV. The purpose of this descriptive qualitative study was to document the underlying social and cultural significance of the sexual cleansing ritual and to assess its impact on HIV prevention strategies. The study participants were selected by purposive and snowball sampling. Data were collected using in-depth interviews, focus group discussions and observations; they were analyzed using content analysis. The article gives detailed explanations of the meanings and symbols of the ritual in its cultural context as a ritual of social transition. Sexual intercourse is perceived as a sacred rite when performed as a ritual. It is associated with most social cultural activities like planting, harvesting, weddings and burial ceremonies. The underlying intention of this ritual is to cleanse evil spirits and to sanctify. Widows who are not cleansed are ostracized and discriminated. The continued practice of the ritual is perpetuated by a shared common belief system that affects social interactions of the community members. Widows and cleansers are believed to be purveyors of the HIV virus. The ritual encourages unprotected sex with multiple partners. These are barriers to HIV prevention strategies that are aimed at changing sexual behaviors.
The burden of tuberculosis (TB) disease in children, particularly in HIV-infected children, is po... more The burden of tuberculosis (TB) disease in children, particularly in HIV-infected children, is poorly described because of a lack of effective diagnostic tests and the emphasis of public health programs on transmissible TB. The objectives of this study were to describe the observed incidence of and risk factors for TB diagnosis among HIV-infected children enrolled in a large network of HIV clinics in western Kenya. Retrospective observational study. The USAID-Academic Model Providing Access to Healthcare (AMPATH) Partnership is Kenya's largest HIV/AIDS care system. Since 2001, the program has enrolled over 70,000 HIV-infected patients in 18 clinics throughout Western Kenya. This analysis included all HIV-infected children aged 0 to 13 years attending an AMPATH clinic. The primary outcome was a diagnosis of any TB, defined either by a recorded diagnosis or by the initiation of anti-TB treatment. Diagnosis of TB is based on a modified Kenneth Jones scoring system and is consistent with WHO case definitions. There were 6535 HIV-infected children aged 0 to 13 years, eligible for analysis, 50.1% were female. Of these, 234 (3.6%) were diagnosed with TB at enrollment. There were subsequently 765 new TB diagnoses in 4368.0 child-years of follow-up for an incidence rate of 17.5 diagnoses (16.3-18.8) per 100 child-years. The majority of these occurred in the first 6 months after enrollment (IR: 106.8 per 100 CY, 98.4-115.8). In multivariable analysis, being severely immune-suppressed at enrollment (Adjusted Hazard Ratio [AHR]: 4.44, 95% CI: 3.62-5.44), having ever attended school AHR: 2.65, 95% CI: 2.15-3.25), being an orphan (AHR: 1.57, 95% CI: 1.28-1.92), being severely low weight-for-height at enrollment (AHR: 1.46, 95% CI: 1.32-1.62), and attending an urban clinic (AHR: 1.39, 95% CI: 1.16-1.67) were all independent risk factors for having an incident TB diagnosis. Children receiving combination antiretroviral treatment were dramatically less likely to be diagnosed with incident TB (AHR: 0.15, 95% CI: 0.12-0.20). These data suggest a high rate of TB diagnosis among HIV-infected children, with severe immune suppression, school attendance, orphan status, very low weight-for-height, and attending an urban clinic being key risk factors. The use of combination antiretroviral treatment reduced the probability of an HIV-infected child being diagnosed with incident TB by 85%.
Background: In resource-poor settings, mortality is at its highest during the first 3 months afte... more Background: In resource-poor settings, mortality is at its highest during the first 3 months after combination antiretroviral treatment (cART) initiation. A clear predictor of mortality during this period is having a low CD4 count at the time of treatment initiation. The objective of this study was to evaluate the effect on survival and clinic retention of a nurse-based rapid assessment clinic for high-risk individuals initiating cART in a resource-constrained setting. Methods: The USAID-AMPATH Partnership has enrolled more than 140,000 patients at 25 clinics throughout western Kenya. High Risk Express Care (HREC) provides weekly or bi-weekly rapid contacts with nurses for individuals initiating cART with CD4 counts of ≤100 cells/mm 3 . All HIV-infected individuals aged 14 years or older initiating cART with CD4 counts of ≤100 cells/mm 3 were eligible for enrolment into HREC and for analysis. Adjusted hazard ratios (AHRs) control for potential confounding using propensity score methods. Results: Between March 2007 and March 2009, 4,958 patients initiated cART with CD4 counts of ≤100 cells/mm 3 . After adjusting for age, sex, CD4 count, use of cotrimoxazole, treatment for tuberculosis, travel time to clinic and type of clinic, individuals in HREC had reduced mortality (AHR: 0.59; 95% confidence interval: 0.45-0.77), and reduced loss to follow up (AHR: 0.62; 95% CI: 0.55-0.70) compared with individuals in routine care. Overall, patients in HREC were much more likely to be alive and in care after a median of nearly 11 months of follow up (AHR: 0.62; 95% CI: 0.57-0.67). Conclusions: Frequent monitoring by dedicated nurses in the early months of cART can significantly reduce mortality and loss to follow up among high-risk patients initiating treatment in resource-constrained settings.
JAIDS Journal of Acquired Immune Deficiency Syndromes, 2006
Main Measures: Orphan status, CD4%, sex-and age-adjusted height (HAZ) and weight (WAZ) z scores, ... more Main Measures: Orphan status, CD4%, sex-and age-adjusted height (HAZ) and weight (WAZ) z scores, ART adherence, mortality.
JAIDS Journal of Acquired Immune Deficiency Syndromes, 2010
To assess whether community-based care delivered by people living with HIV/AIDS (PLWAs) could rep... more To assess whether community-based care delivered by people living with HIV/AIDS (PLWAs) could replace clinic-based HIV care. Prospective cluster randomized controlled clinical trial. Villages surrounding 1 rural clinic in western Kenya. HIV-infected adults clinically stable on antiretroviral therapy (ART). The intervention group received monthly Personal Digital Assistant supported home assessments by PLWAs with clinic appointments every 3 months. The control group received standard of care monthly clinic visits. Viral load, CD4 count, Karnofsky score, stability of ART regimen, opportunistic infections, pregnancies, and number of clinic visits. After 1 year, there were no significant intervention-control differences with regard to detectable viral load, mean CD4 count, decline in Karnofsky score, change in ART regimen, new opportunistic infection, or pregnancy rate. Intervention patients made half as many clinic visits as did controls (P < 0.001). Community-based care by PLWAs resulted in similar clinical outcomes as usual care but with half the number of clinic visits. This pilot study suggests that task-shifting and mobile technologies can deliver safe and effective community-based care to PLWAs, expediting ART rollout and increasing access to treatment while expanding the capacity of health care institutions in resource-constrained environments.
International Journal of Medical Informatics, 2005
Administering and monitoring therapy is crucial to the battle against HIV/AIDS in sub-Saharan Afr... more Administering and monitoring therapy is crucial to the battle against HIV/AIDS in sub-Saharan Africa. Electronic medical records (EMRs) can aid in documenting care, monitoring drug adherence and response to therapy, and providing data for quality improvement and research.
International Journal of Medical Informatics, 2000
Mosoriot Health Center is a rural primary care facility situated on the outskirts of Eldoret, Ken... more Mosoriot Health Center is a rural primary care facility situated on the outskirts of Eldoret, Kenya in sub-Saharan Africa. The region is characterised by widespread poverty and a very poor technology infrastructure. Many houses do not have electricity, telephones or tap water. The health center does have electricity and tap water. In a collaborative project between Indiana University and the Moi University Faculty of Health Sciences (MUFHS), we designed a core electronic medical record system within the Mosoriot Health Center, with the intention of improving the quality of health data collection and, subsequently, patient care. The electronic medical record system will also be used to link clinical data from the health center to information collected from the public health surveys performed by medical students participating in the public health research programs of Moi University. This paper describes the processes involved in the development of the computer-based Mosoriot medical record system (MMRS) up to the point of implementation. It particularly focuses on the decisions and trade-offs that must be made when introducing this technology into an established health care system in a developing country.
To describe the perceptions of key stakeholders regarding the counselling needs of HIV sero-disco... more To describe the perceptions of key stakeholders regarding the counselling needs of HIV sero-discordant couples as part of preparation for a clinical trial involving HIV sero-discordant couples. Qualitative study using key informant and couple interviews. Moi Teaching and Referral Hospital (MTRH). A purposive sample of nine key informants and 31 couple interviews totaling 71 participants. The couple interviews consisted of HIV untested, HIV concordant (positive and negative) and discordant couples. Seventy one individuals participated in nine key informant and 31 couple interviews. The responses identified the following as key issues in counselling HIV discordant couples: The need for education on the meaning of HIV sero-discordancy including potential sources of infection; assistance in disclosing HIV test results to one's partner; discussion of the stigma surrounding formula feeding. Overall, the participants supported safer sexual practices in discordant partnerships. Psychosocial support of HIV sero-discordant couples should include messages about the meaning, mechanisms and implications of sero-discordancy. Culturally appropriate HIV-disclosure and safer sex messages are also needed to support these partnerships.
This paper reports on an exploratory study examining the role of sexual cleansing rituals in the ... more This paper reports on an exploratory study examining the role of sexual cleansing rituals in the transmission of HIV among the Luo community in western Kenya. Data were collected using both in-depth interviews and focus group discussions. The study population consisted of 38 widows, 12 community elders and 44 cleansers. Data were collected on non-behavioural causes, behavioural causes and behavioural indicators associated with sexual rituals. Content analysis revealed five central themes: the effect of the ritual on sexual behaviours; factors contributing to the continued practice of the ritual, including a sub-theme on the commercialization of the ritual; the inseparable relationship between the sanctity of sex, prosperity and fertility of the land; and the effects of modernization on the ritual, including a sub-theme on the effects of mass media on HIV-prevention awareness campaigns. Causal factors of unchanging sexual behaviours are deeply rooted in traditional beliefs, which the community uphold strongly. These beliefs encourage men and women to have multiple sexual partners in a context where the use of condoms is rejected and little HIV testing is carried out.
Two-thirds of those with HIV worldwide live in sub-Saharan Africa. Alcohol use is associated with... more Two-thirds of those with HIV worldwide live in sub-Saharan Africa. Alcohol use is associated with the HIV epidemic through risky sex and suboptimal ARV adherence. In western Kenya, hazardous drinking was reported by HIV (53%) and general medicine (68%) outpatients. Cognitive behavioral treatment (CBT) has demonstrated strong efficacy to reduce alcohol use. This article reports on a systematic cultural adaptation and pilot feasibility study of group paraprofessional-delivered CBT to reduce alcohol use among HIV-infected outpatients in Eldoret, Kenya. Following adaptation and counselor training, five pilot groups were run (n=27). Overall attendance was 77%. Percent days abstinent from alcohol (PDA) before session 1 was 52%-100% (women) and 21-36% (men), and by session 6 was 96%-100% (women) and 89%-100% (men). PDA effect sizes (Cohen's d) between first and last CBT session were 2.32 (women) and 2.64 (men). Participants reported treatment satisfaction. Results indicate feasibility, acceptability and preliminary efficacy for CBT in Kenya.
Issues: Concurrent sexual partnerships establish network connectivity in populations with low rat... more Issues: Concurrent sexual partnerships establish network connectivity in populations with low rates of partner acquisition. This can accelerate the spread of HIV infection. National and international health and development agencies working in highly affected African countries have called for interventions to reduce multiple and concurrent partnerships (MCP). Description: The Know Your Network intervention (KYN) uses interactive exercises and a PDA survey of participants' sexual behavior to illustrate the impact of MCP. Researchers and study participants in western Kenyan communities with high HIV prevalence collaborated to develop KYN, and this project conducts formative research and elicits community and health care worker feedback to a trial run of KYN. Methods: We will use mabaraza (community meetings) and focus group discussions (FGD) to engage village leaders and community members in this project. Mabaraza with chiefs and elders will take place in April 2010. We will use qu...
Studies in health technology and informatics, 2007
Providing high-quality HIV/AIDS care requires high-quality, accessible data on individual patient... more 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, a...
Mosoriot Health Center is a rural primary care facility situated on the outskirts of Eldoret, Ken... more Mosoriot Health Center is a rural primary care facility situated on the outskirts of Eldoret, Kenya in sub-Saharan Africa. The region is characterised by widespread poverty and a very poor technology infrastructure. Many houses do not have electricity, telephones or tap water. The health center does have electricity and tap water. In a collaborative project between Indiana University and the Moi University Faculty of Health Sciences (MUFHS), we designed a core electronic medical record system within the Mosoriot Health Center, with the intention of improving the quality of health data collection and, subsequently, patient care. The electronic medical record system will also be used to link clinical data from the health center to information collected from the public health surveys performed by medical students participating in the public health research programs of Moi University. This paper describes the processes involved in the development of the computer-based Mosoriot medical record system (MMRS) up to the point of implementation. It particularly focuses on the decisions and trade-offs that must be made when introducing this technology into an established health care system in a developing country.
Studies in health technology and informatics, 2010
Efficient use of health care resources in low-income countries by providers and local and nationa... more Efficient use of health care resources in low-income countries by providers and local and national managers requires timely access to patient data. To implement electronic health records (EHRs) in HIV clinics in Kenya, Tanzania, and Uganda. We initially developed and implemented an EHR in Kenya through a mature academic partnership. The EHR was then implemented in six HIV clinics in Tanzania and Uganda in collaboration with their National AIDS Control Programmes. All implementations were successful, but the system's use and sustainability varied depending on who controlled clinic funding. Successful EHR use and sustainability were enhanced by local control of funds, academic partnerships (mainly by leveraging research funds), and in-country technology support.
SAHARA-J: Journal of Social Aspects of HIV/AIDS, 2009
Clinical programmes are typically evaluated on operational performance metrics of cost, quality a... more Clinical programmes are typically evaluated on operational performance metrics of cost, quality and outcomes. Measures of patient satisfaction are used to assess the experience of receiving care, but other perspectives, including those of staff and communities, are not often sought or used to assess and improve programmes. For strategic planning, the Kenyan HIV/AIDS programme AMPATH (Academic Model Providing Access to Healthcare) sought to evaluate its performance in 2006. The method used for this evaluation was termed 'triangulation, ' because it used information from three different sources -patients, communities, and programme staff. From January to August 2006, Indiana University external evaluators and AMPATH staff gathered information on strengths, weaknesses and suggestions for improvement of AMPATH. Activities included in-depth key-informant semi-structured interviews of 26 AMPATH clinical and support staff, 56 patients at eight clinic sites, and seven village health dialogues (mabaraza) at five sublocations within the AMPATH catchment area. Data sources included field notes and transcripts of translated audio recordings, which were subjected to qualitative content analysis. Eighteen recommendations for programme improvement emerged, including ten from all three respondent perspectives. Three recommendations were cited by patients and in mabaraza, but not by staff.
Jaids-journal of Acquired Immune Deficiency Syndromes, 2009
In 2001, HIV postexposure prophylaxis (PEP) was initiated in western Kenya. Design, implementatio... more In 2001, HIV postexposure prophylaxis (PEP) was initiated in western Kenya. Design, implementation, and evolution of the PEP program are described. Patient data were analyzed for reasons, time to initiation, and PEP outcome. Occupational PEP was initiated first followed by nonoccupational PEP (nPEP). Antiretroviral regimens were based upon national PEP guidelines, affordability and availability, and prevailing HIV prevalence. Emerging side effects data and cost improvements influenced regimen changes. Between November 2001 and December 2006, 446 patients sought PEP. Occupational exposure: 91 patients: 51 males; 72 accepted HIV testing; 48 of 52 source patients were HIV infected; median exposure-PEP time 3 hours (range: 0.3-96 hours). Of 72 HIV-negative patients receiving PEP, 3 discontinued, 69 completed, and 23 performed post-PEP HIV RNA polymerase chain reaction (all negative). Eleven follow-up HIV enzyme-linked immunosorbent assay tests have all turned negative. Nonoccupational exposure: 355 patients; 285 females; 90 children; 300 accepted HIV testing; median exposure-nPEP time 19 hours (range: 1-672 hours). Of 296 HIV-negative patients on nPEP, 1 died, 15 discontinued, 104 are on record having completed PEP, and 129 returned for 6-week HIV RNA polymerase chain reaction (1 patient tested positive). Eighty-seven follow-up HIV enzyme-linked immunosorbent assay tests have all turned negative. It is feasible to provide PEP and nPEP in resource-constrained settings.
Traditional cultural practices and sexual rituals have an important role in the life and structur... more Traditional cultural practices and sexual rituals have an important role in the life and structure of tribal groups within Kenya. These cultural practices and rituals also play a significant role in the spread of HIV. The purpose of this descriptive qualitative study was to document the underlying social and cultural significance of the sexual cleansing ritual and to assess its impact on HIV prevention strategies. The study participants were selected by purposive and snowball sampling. Data were collected using in-depth interviews, focus group discussions and observations; they were analyzed using content analysis. The article gives detailed explanations of the meanings and symbols of the ritual in its cultural context as a ritual of social transition. Sexual intercourse is perceived as a sacred rite when performed as a ritual. It is associated with most social cultural activities like planting, harvesting, weddings and burial ceremonies. The underlying intention of this ritual is to cleanse evil spirits and to sanctify. Widows who are not cleansed are ostracized and discriminated. The continued practice of the ritual is perpetuated by a shared common belief system that affects social interactions of the community members. Widows and cleansers are believed to be purveyors of the HIV virus. The ritual encourages unprotected sex with multiple partners. These are barriers to HIV prevention strategies that are aimed at changing sexual behaviors.
The burden of tuberculosis (TB) disease in children, particularly in HIV-infected children, is po... more The burden of tuberculosis (TB) disease in children, particularly in HIV-infected children, is poorly described because of a lack of effective diagnostic tests and the emphasis of public health programs on transmissible TB. The objectives of this study were to describe the observed incidence of and risk factors for TB diagnosis among HIV-infected children enrolled in a large network of HIV clinics in western Kenya. Retrospective observational study. The USAID-Academic Model Providing Access to Healthcare (AMPATH) Partnership is Kenya's largest HIV/AIDS care system. Since 2001, the program has enrolled over 70,000 HIV-infected patients in 18 clinics throughout Western Kenya. This analysis included all HIV-infected children aged 0 to 13 years attending an AMPATH clinic. The primary outcome was a diagnosis of any TB, defined either by a recorded diagnosis or by the initiation of anti-TB treatment. Diagnosis of TB is based on a modified Kenneth Jones scoring system and is consistent with WHO case definitions. There were 6535 HIV-infected children aged 0 to 13 years, eligible for analysis, 50.1% were female. Of these, 234 (3.6%) were diagnosed with TB at enrollment. There were subsequently 765 new TB diagnoses in 4368.0 child-years of follow-up for an incidence rate of 17.5 diagnoses (16.3-18.8) per 100 child-years. The majority of these occurred in the first 6 months after enrollment (IR: 106.8 per 100 CY, 98.4-115.8). In multivariable analysis, being severely immune-suppressed at enrollment (Adjusted Hazard Ratio [AHR]: 4.44, 95% CI: 3.62-5.44), having ever attended school AHR: 2.65, 95% CI: 2.15-3.25), being an orphan (AHR: 1.57, 95% CI: 1.28-1.92), being severely low weight-for-height at enrollment (AHR: 1.46, 95% CI: 1.32-1.62), and attending an urban clinic (AHR: 1.39, 95% CI: 1.16-1.67) were all independent risk factors for having an incident TB diagnosis. Children receiving combination antiretroviral treatment were dramatically less likely to be diagnosed with incident TB (AHR: 0.15, 95% CI: 0.12-0.20). These data suggest a high rate of TB diagnosis among HIV-infected children, with severe immune suppression, school attendance, orphan status, very low weight-for-height, and attending an urban clinic being key risk factors. The use of combination antiretroviral treatment reduced the probability of an HIV-infected child being diagnosed with incident TB by 85%.
Background: In resource-poor settings, mortality is at its highest during the first 3 months afte... more Background: In resource-poor settings, mortality is at its highest during the first 3 months after combination antiretroviral treatment (cART) initiation. A clear predictor of mortality during this period is having a low CD4 count at the time of treatment initiation. The objective of this study was to evaluate the effect on survival and clinic retention of a nurse-based rapid assessment clinic for high-risk individuals initiating cART in a resource-constrained setting. Methods: The USAID-AMPATH Partnership has enrolled more than 140,000 patients at 25 clinics throughout western Kenya. High Risk Express Care (HREC) provides weekly or bi-weekly rapid contacts with nurses for individuals initiating cART with CD4 counts of ≤100 cells/mm 3 . All HIV-infected individuals aged 14 years or older initiating cART with CD4 counts of ≤100 cells/mm 3 were eligible for enrolment into HREC and for analysis. Adjusted hazard ratios (AHRs) control for potential confounding using propensity score methods. Results: Between March 2007 and March 2009, 4,958 patients initiated cART with CD4 counts of ≤100 cells/mm 3 . After adjusting for age, sex, CD4 count, use of cotrimoxazole, treatment for tuberculosis, travel time to clinic and type of clinic, individuals in HREC had reduced mortality (AHR: 0.59; 95% confidence interval: 0.45-0.77), and reduced loss to follow up (AHR: 0.62; 95% CI: 0.55-0.70) compared with individuals in routine care. Overall, patients in HREC were much more likely to be alive and in care after a median of nearly 11 months of follow up (AHR: 0.62; 95% CI: 0.57-0.67). Conclusions: Frequent monitoring by dedicated nurses in the early months of cART can significantly reduce mortality and loss to follow up among high-risk patients initiating treatment in resource-constrained settings.
JAIDS Journal of Acquired Immune Deficiency Syndromes, 2006
Main Measures: Orphan status, CD4%, sex-and age-adjusted height (HAZ) and weight (WAZ) z scores, ... more Main Measures: Orphan status, CD4%, sex-and age-adjusted height (HAZ) and weight (WAZ) z scores, ART adherence, mortality.
JAIDS Journal of Acquired Immune Deficiency Syndromes, 2010
To assess whether community-based care delivered by people living with HIV/AIDS (PLWAs) could rep... more To assess whether community-based care delivered by people living with HIV/AIDS (PLWAs) could replace clinic-based HIV care. Prospective cluster randomized controlled clinical trial. Villages surrounding 1 rural clinic in western Kenya. HIV-infected adults clinically stable on antiretroviral therapy (ART). The intervention group received monthly Personal Digital Assistant supported home assessments by PLWAs with clinic appointments every 3 months. The control group received standard of care monthly clinic visits. Viral load, CD4 count, Karnofsky score, stability of ART regimen, opportunistic infections, pregnancies, and number of clinic visits. After 1 year, there were no significant intervention-control differences with regard to detectable viral load, mean CD4 count, decline in Karnofsky score, change in ART regimen, new opportunistic infection, or pregnancy rate. Intervention patients made half as many clinic visits as did controls (P < 0.001). Community-based care by PLWAs resulted in similar clinical outcomes as usual care but with half the number of clinic visits. This pilot study suggests that task-shifting and mobile technologies can deliver safe and effective community-based care to PLWAs, expediting ART rollout and increasing access to treatment while expanding the capacity of health care institutions in resource-constrained environments.
International Journal of Medical Informatics, 2005
Administering and monitoring therapy is crucial to the battle against HIV/AIDS in sub-Saharan Afr... more Administering and monitoring therapy is crucial to the battle against HIV/AIDS in sub-Saharan Africa. Electronic medical records (EMRs) can aid in documenting care, monitoring drug adherence and response to therapy, and providing data for quality improvement and research.
International Journal of Medical Informatics, 2000
Mosoriot Health Center is a rural primary care facility situated on the outskirts of Eldoret, Ken... more Mosoriot Health Center is a rural primary care facility situated on the outskirts of Eldoret, Kenya in sub-Saharan Africa. The region is characterised by widespread poverty and a very poor technology infrastructure. Many houses do not have electricity, telephones or tap water. The health center does have electricity and tap water. In a collaborative project between Indiana University and the Moi University Faculty of Health Sciences (MUFHS), we designed a core electronic medical record system within the Mosoriot Health Center, with the intention of improving the quality of health data collection and, subsequently, patient care. The electronic medical record system will also be used to link clinical data from the health center to information collected from the public health surveys performed by medical students participating in the public health research programs of Moi University. This paper describes the processes involved in the development of the computer-based Mosoriot medical record system (MMRS) up to the point of implementation. It particularly focuses on the decisions and trade-offs that must be made when introducing this technology into an established health care system in a developing country.
To describe the perceptions of key stakeholders regarding the counselling needs of HIV sero-disco... more To describe the perceptions of key stakeholders regarding the counselling needs of HIV sero-discordant couples as part of preparation for a clinical trial involving HIV sero-discordant couples. Qualitative study using key informant and couple interviews. Moi Teaching and Referral Hospital (MTRH). A purposive sample of nine key informants and 31 couple interviews totaling 71 participants. The couple interviews consisted of HIV untested, HIV concordant (positive and negative) and discordant couples. Seventy one individuals participated in nine key informant and 31 couple interviews. The responses identified the following as key issues in counselling HIV discordant couples: The need for education on the meaning of HIV sero-discordancy including potential sources of infection; assistance in disclosing HIV test results to one's partner; discussion of the stigma surrounding formula feeding. Overall, the participants supported safer sexual practices in discordant partnerships. Psychosocial support of HIV sero-discordant couples should include messages about the meaning, mechanisms and implications of sero-discordancy. Culturally appropriate HIV-disclosure and safer sex messages are also needed to support these partnerships.
This paper reports on an exploratory study examining the role of sexual cleansing rituals in the ... more This paper reports on an exploratory study examining the role of sexual cleansing rituals in the transmission of HIV among the Luo community in western Kenya. Data were collected using both in-depth interviews and focus group discussions. The study population consisted of 38 widows, 12 community elders and 44 cleansers. Data were collected on non-behavioural causes, behavioural causes and behavioural indicators associated with sexual rituals. Content analysis revealed five central themes: the effect of the ritual on sexual behaviours; factors contributing to the continued practice of the ritual, including a sub-theme on the commercialization of the ritual; the inseparable relationship between the sanctity of sex, prosperity and fertility of the land; and the effects of modernization on the ritual, including a sub-theme on the effects of mass media on HIV-prevention awareness campaigns. Causal factors of unchanging sexual behaviours are deeply rooted in traditional beliefs, which the community uphold strongly. These beliefs encourage men and women to have multiple sexual partners in a context where the use of condoms is rejected and little HIV testing is carried out.
Two-thirds of those with HIV worldwide live in sub-Saharan Africa. Alcohol use is associated with... more Two-thirds of those with HIV worldwide live in sub-Saharan Africa. Alcohol use is associated with the HIV epidemic through risky sex and suboptimal ARV adherence. In western Kenya, hazardous drinking was reported by HIV (53%) and general medicine (68%) outpatients. Cognitive behavioral treatment (CBT) has demonstrated strong efficacy to reduce alcohol use. This article reports on a systematic cultural adaptation and pilot feasibility study of group paraprofessional-delivered CBT to reduce alcohol use among HIV-infected outpatients in Eldoret, Kenya. Following adaptation and counselor training, five pilot groups were run (n=27). Overall attendance was 77%. Percent days abstinent from alcohol (PDA) before session 1 was 52%-100% (women) and 21-36% (men), and by session 6 was 96%-100% (women) and 89%-100% (men). PDA effect sizes (Cohen's d) between first and last CBT session were 2.32 (women) and 2.64 (men). Participants reported treatment satisfaction. Results indicate feasibility, acceptability and preliminary efficacy for CBT in Kenya.
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Papers by John Sidle