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

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

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

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

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

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

Key variables and outcomes (2)

• Quality of care– Assessment of ART eligibility

(CD4/WHO), prompt ART initiation

• Patient retention1. 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

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

Results

Patient volume

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

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

Facility characteristics

Clinic location, nurse ART provision, and presence of CD4

machine on-site

Loca

ted

in rura

l are

a

Nurs

e pr

ovisio

n of A

RT

CD4

mac

hine on

site

0%

20%

40%

60%

80%

100%

Primary Health Facilities Secondary Health Facilities

% o

f fa

cil

itie

s

Patient characteristics

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%

Point of entry to HIV care

 Primary

HFSecondar

y HF(n=3,881

)(n=22,80

9)

Transferred in 20% 12%

VCT 19% 29%

PMTCT 12% 9%

TB/HIV 5% 6%

PITC 3% 6%

Unknown/other

41% 34%

Characteristics of patients starting ART

  Primary HFSecondary

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%

Quality of care: ART eligibility assessment

and prompt initiation

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 pati

en

ts

0%

40%

80%

Percent of patients ART-eli-gible at enrollment who

started ART

Primary HF Secondary HF

% o

f pati

en

ts

Patient retention: Death and loss to follow-up

(LTF)

Death following enrollment in HIV care (pre-ART)

Adjusted SHR=1.2995% CI: (0.91-1.84)

Adjusted SHR=0.77 95% CI: (0.62-0.97)

LTF following enrollment in HIV care (pre-ART)

Death following ART initiation

Adjusted HR=0.94 95% CI: (0.67-1.32)

LTF following ART initiation

Adjusted HR=0.67 95% CI: (0.27-1.65)

Adjusted S/HR of non-retention in Primary vs. Secondary HF

  

All patients

   Adjusted S/HR*

95% CI

Pre-ART Death 1.290.91-1.84

LTF 0.770.62-0.97

ART Death 0.940.67-1.32

LTF 0.670.27-1.65*Reference category: Secondary HF. Models control for WHO stage,

CD4 count, age group, gender, year of patient enrollment in care or ART initiation

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% CIAdjusted S/HR*

95% CI

Pre-ART Death 1.290.91-1.84

1.320.92-1.89

LTF 0.770.62-0.97

0.840.66-1.07

ART Death 0.940.67-1.32

0.940.65-1.35

LTF 0.670.27-1.65

0.720.28-1.82

*Reference category: Secondary HF. Models control for WHO stage, CD4 count, age group, gender, year of patient enrollment in care or ART initiation

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

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