BACKGROUND:Cascades have been used to characterize sequential steps within a complex health system and are used in diverse disease areas and across prevention, testing, and treatment. Routine data ...have great potential to inform prioritization within a system, but are often inaccessible to frontline health care workers (HCWs) who may have the greatest opportunity to innovate health system improvement.
METHODS:The cascade analysis tool (CAT) is an Excel-based, simple simulation model with an optimization function. It identifies the step within a cascade that could most improve the system. The original CAT was developed for HIV treatment and the prevention of mother-to-child transmission of HIV.
RESULTS:CAT has been adapted 7 timesto a mobile application for prevention of mother-to-child transmission; for hypertension screening and management and for mental health outpatient services in Mozambique; for pediatric and adolescent HIV testing and treatment, HIV testing in family planning, and cervical cancer screening and treatment in Kenya; and for naloxone distribution and opioid overdose reversal in the United States. The main domains of adaptation have been technical—estimating denominators and structuring steps to be binary sequential steps—as well as logistical—identifying acceptable approaches for data abstraction and aggregation, and not overburdening HCW.
DISCUSSION:CAT allows for prompt feedback to HCWs, increases HCW autonomy, and allows managers to allocate resources and time in an equitable manner. CAT is an effective, feasible, and acceptable implementation strategy to prioritize areas most requiring improvement within complex health systems, although adaptations are being currently evaluated.
Kenya is one of the first African countries to scale up a national HIV viral load monitoring program. We sought to assess program scale up using the national database and identify areas for systems ...strengthening.
Data from January 2012 to March 2016 were extracted from Kenya's national viral load database. Characteristics of 1,108,356 tests were assessed over time, including reason for testing, turnaround times, test results, treatment regimens, and socio-demographic information.
The number of facilities offering viral load testing increased to ~2,000 with >40,000 tests being conducted per month by 2016. By March 2016, most (84.2%) tests were conducted for routine monitoring purposes and the turnaround time from facility-level sample collection to result dispatch from the lab was 21(24) median (IQR) days. Although the proportions of repeat viral load tests increased over time, the volumes were lower than expected. Elevated viral load was much more common in pediatric and adolescent patients (0-<3 years: 43.1%, 3-<10 years: 34.5%, 10-<20 years: 36.6%) than in adults (30-<60 years: 13.3%; p<0.001).
Coverage of viral load testing dramatically increased in Kenya to >50% of patients on antiretroviral therapy (ART) by early 2016 and represents a relatively efficient laboratory system. However, strengthening of patient tracking mechanisms and viral load result utilization may be necessary to further improve the system. Additional focus is needed on paediatric/adolescent patients to improve viral suppression in these groups. Kenya's national viral load database has demonstrated its usefulness in assessing laboratory programs, tracking trends in patient characteristics, monitoring scale-up of new policies and programs, and identifying problem areas for further investigation.
Background:
Pediatric HIV testing remains suboptimal. The OraQuick test saliva-based test (SBT) is validated in pediatric populations ≥18 months. Understanding caregiver and health care worker (HCW) ...acceptability of pediatric SBT is critical for implementation.
Methods:
A trained qualitative interviewer conducted 8 focus group discussions (FGDs): 4 with HCWs and 4 with caregivers of children seeking health services in western Kenya. FGDs explored acceptability of pediatric SBT and home- and facility-based SBT use. Two reviewers conducted consensus coding and thematic analyses of transcripts using Dedoose.
Results:
Most HCWs but few caregivers had heard of SBT. Before seeing SBT instructions, both had concerns about potential HIV transmission through saliva, which were mostly alleviated after kit demonstration. Noted benefits of SBT included usability and avoiding finger pricks. Benefits of facility-based pediatric SBT included shorter client waiting and service time, higher testing coverage, and access to HCWs, while noted challenges included ensuring confidentiality. Benefits of caregivers using home-based SBT included convenience, privacy, decreased travel costs, increased testing, easier administration, and child comfort. Perceived challenges included not receiving counseling, disagreements with partners, child neglect, and negative emotional response to a positive test result. Overall, HCWs felt that SBT could be used for pediatric HIV testing but saw limited utility for caregivers performing SBT without an HCW present. Caregivers saw utility in home-based SBT but wanted easy access to counseling in case of a positive test result.
Conclusions:
SBT was generally acceptable to HCWs and caregivers and is a promising strategy to expand testing coverage.
BACKGROUND:Repeat HIV viral load (VL) testing is required after unsuppressed VL to confirm treatment failure. We assessed proportion of adolescents and young adults living with HIV (AYALHIV) in Kenya ...with a confirmatory VL test and time to repeat testing.
DESIGN:A retrospective analysis of longitudinal data abstracted from Kenyaʼs national VL database.
METHODS:VL data for AYALHIV who were 10–24 year old between April 2017 and May 2019 were abstracted from 117 HIV care clinics. Records were eligible if at least one VL test was performed ≥6 months after antiretroviral therapy (ART) initiation. The proportion of unsuppressed AYALHIV (≥1000 copies/mL) and time in months between first unsuppressed VL and repeat VL was determined.
RESULTS:We abstracted 40,928 VL records for 23,969 AYALHIV; of whom, 17,092 (71%) were eligible for this analysis. Of these, 12,122 (71%) were women, median age of 19 years interquartile range (IQR)13–23, and median ART duration of 38 months (IQR16–76). Among eligible AYALHIV, 4010 (23%) had an unsuppressed VL at first eligible measurement. Only 316 (8%) of the unsuppressed AYALHIV had a repeat VL within 3 months and 1176 (29%) within 6 months. Among 2311 virally unsuppressed AYALHIV with a repeat VL, the median time between the first and the repeat VL was 6 months (IQR4–8), with 1330 (58%) having confirmed treatment failure.
CONCLUSIONS:One-quarter of AYALHIV on ART had unsuppressed VL, with less than a third receiving a repeat VL within 6 months. Strategies to improve VL testing practices are needed to improve AYALHIVʼs outcomes.
•The is need for contextual demystification of barriers to sick young infant community follow up and strengthening care seeking dynamics including prompt action at individual, household, and ...community levels.•Sustainable integrated communication strategies can be used to achieve data capture critical in strengthening community-facility linkage. This could be achieved by use of local resources, including community health volunteers.•Timely availability of essential commodities is critical for uninterrupted provision of care and treatment to sick young infants.•Strengthening of the community system through empowerment, resource allocation, and continuous engagement is essential for sustainability of community referral and follow up of sick young infants.
Management of possible severe bacterial infections in young infants (0–59 days) requires timely identification of danger signs and prompt administration of efficacious antibiotic treatment. The Possible Severe Bacterial Infection guidelines underscore the importance of close follow up in an outpatient basis to ensure treatment adherence and early detection of illness-related complications. The purpose of this study was to strengthen the follow up and referral of sick young infants on day 4 and 8 by introducing community-led interventions that facilitated community health volunteers to identify sick young infants, conduct community reviews, link data with responsive facilities, and refer appropriately.
Six health facilities were included in a longitudinal, descriptive, mixed methods approach weaved around an initial formative context assessment and three-monthly assessments between October 2019 to January 2020 with a endline assessment in August 2020. Quantitative data was extracted from facility registers to identify gaps in follow up and referral feasibility. Qualitative data was through focus group discussions with community health volunteers and key informant interviews with frontline providers.
Qualitative data provided insights into key barriers and facilitators of community follow up and referral. Barriers include community socio-cultural practices, competing tasks, dysfunctional community referral pathway, drivers of common infections, and unavailability of essential commodities. Key facilitators entail indication of competency in identification of danger signs in sick young infants, presence of older women, men, and community resource persons that can leveraged on in community engagement and sensitization, and mothers are the primary decision makers in care seeking. There was increased utilization of decision support tools and an increase in the number of sick young infants managed in dispensaries. The COVID-19 pandemic however negatively impacted community follow up and referral of sick young infants.
Essential barriers and facilitators to follow up and community referral entwined with facility-based vulnerabilities were highlighted. A two-pronged intervention on improving communication, linkage and subsequent follow up of sick young infants was employed in the six participating facilities. The feasibility, adoption, and fidelity of strengthening community facility linkage through integrated communication strategies was documented, indicative of a successful community-facility linkage in dispensaries and health centers despite the effects of the COVID-19 pandemic.
Since the onset of the recent COVID-19 pandemic, there have been growing concerns regarding multisystem inflammatory syndrome in children (MIS-C). This study aims to describe the ...clinico-epidemiological profile and challenges in management of MIS-C in low-middle income countries by highlighting the Kenyan experience.
A retrospective study at the Aga Khan University Hospital Nairobi, Avenue Hospital Kisumu and Kapsabet County Referral Hospital was undertaken to identify cases of MIS-C. A detailed chart review using the World Health Organization (WHO) data collection tool was adapted to incorporate information on socio-demographic details and treatment regimens.
Twenty children with MIS-C were identified across the three facilities between August 1st 2020 and August 31st 2021. Seventy percent of the children were male (14 of 20). COVID-19 PCR testing was done for five children and only one was positive. The commonest clinical symptoms were fever (90%), tachycardia (80%), prolonged capillary refill (80%), oral mucosal changes (65%) and peripheral cutaneous inflammation (50%). Four children required admission into the critical care unit for ventilation support and inotropic support. Cardiac evaluation was available for six patients four of whom had myocardial dysfunction, three had valvulitis and one had pericarditis. Immunoglobulin therapy was availed to two children and systemic steroids provided for three children. There were no documented mortalities.
We describe the first case series of MIS-C in East and Central Africa. Majority of suspected cases of MIS-C did not have access to timely COVID-19 testing and other appropriate evaluations which highlights the iniquity in access to diagnostics and treatment.
IntroductionSuccessfully transitioning adolescents to adult HIV care is critical for optimising outcomes. Disclosure of HIV status, a prerequisite to transition, remains suboptimal in sub-Saharan ...Africa. Few interventions have addressed both disclosure and transition. An adolescent transition package (ATP) that combines disclosure and transition tools could support transition and improve outcomes.Methods and analysisIn this hybrid type 1 effectiveness-implementation cluster randomised controlled trial, 10 HIV clinics with an estimated ≥100 adolescents and young adults age 10–24 living with HIV (ALWHIV) in Kenya will be randomised to implement the ATP and compared with 10 clinics receiving standard of care. The ATP includes provider tools to assist disclosure and transition. Healthcare providers at intervention clinics will receive training on ATP use and support to adapt it through continuous quality improvement cycles over the initial 6 months of the study, with continued implementation for 1 year. The primary outcome is transition readiness among ALWHIV ages 15–24 years, assessed 6 monthly using a 22-item readiness score. Secondary outcomes including retention and viral suppression among ALWHIV at the end of the intervention period (month 18), implementation outcomes (acceptability, feasibility, fidelity, coverage and penetration) and programme costs complement effectiveness outcomes. The primary analysis will be intent to treat, using mixed-effects linear regression models to compare transition readiness scores (overall and by domain (HIV literacy, self-management, communication, support)) over time in control and intervention sites with adjustment for multiple testing, accounting for clustering by clinic and repeated assessments. We will estimate the coefficients and 95% CIs with a two- sided α=0.05.Ethics and disseminationThe study was approved by the University of Washington Institutional Review Board and the Kenyatta National Hospital Ethics and Research Committee. Study results will be shared with participating facilities, county and national policy-makers.Trials registration numberNCT03574129; Pre-results.
Disclosure of HIV status to adolescents living with HIV has been associated with improved treatment outcomes. However, there are limited data regarding the experiences of, perceptions of, and ...preferences for the process of disclosure of HIV status among adolescents and young adults living with HIV (AYLH), especially in sub-Saharan Africa.
Young adults living with HIV from 20 HIV clinics in Kenya who participated in a clinical trial evaluating the effectiveness of a disclosure and transition package completed an anonymous survey in 2019. We described their experiences and preferences using counts and proportions and assessed factors associated with satisfaction with the disclosure process using linear regression, reporting age-adjusted mean differences (aMD), and 95% confidence intervals (95%CIs).
Of the 375 enrolled AYLH, 265 (71%) had perinatally acquired HIV, of whom 162 (61%) were female. The median age of the enrolled AYLH was 16 years (IQR: 14-19 years), and all of them were on antiretroviral therapy (ART). For over half (55%) of the participants, caregivers disclosed their HIV status, and 57% preferred that their caregivers disclose the status to them. Most (78%) of the participants preferred full disclosure by 12 years of age. The majority (69%) believed the disclosure was planned, and 11% suspected being HIV positive before the disclosure. Overall, 198 (75%) AYLH reported that they were ready for disclosure when it happened, and 86% were satisfied with the process. During both pre-disclosure (67 and 70%, respectively) and post-disclosure (>75% for each), AYLH felt supported by the clinic and caregivers. Factors associated with higher satisfaction with the disclosure process were pre-disclosure clinic support (aMD: 0.19 95%CI: 0.05-0.33) and pre-disclosure (aMD: 0.19 0.06-0.31) and post-disclosure (aMD: 0.17 0.03-0.31) caregiver support. AYLH who suspected they were HIV positive before they were disclosed to tended to have lower satisfaction when compared to those who never suspected (aMD: -0.37 -0.74-(-0.01)). Overall, they reported that disclosure positively influenced their ART adherence (78%), clinic attendance (45%), and communication with caregivers (20%), and 40% reported being happier after disclosure.
Young adults living with HIV advocated for an appropriately timed disclosure process with the involvement of caregivers and healthcare workers (HCWs). Support from caregivers and HCWs before and during disclosure is key to improving their disclosure experience.
Children and adolescents lag behind adults in achieving UNAIDS 95-95-95 targets for HIV testing, treatment, and viral suppression. The Systems Analysis and Improvement Approach (SAIA) is a ...multi-component implementation strategy previously shown to improve the HIV care cascade for pregnant women and infants. SAIA merits adaptation and testing to reduce gaps in the pediatric and adolescent HIV cascade.
We adapted the SAIA strategy components to be applicable to the pediatric and adolescent HIV care cascade (SAIA-PEDS) in Nairobi and western Kenya. We tested whether this SAIA-PEDS strategy improved HIV testing, linkage to care, antiretroviral treatment (ART), viral load (VL) testing, and viral load suppression for children and adolescents ages 0-24 years at 5 facilities. We conducted a pre-post analysis with 6 months pre- and 6 months post-implementation strategy (coupled with an interrupted time series sensitivity analysis) using abstracted routine program data to determine changes attributable to SAIA-PEDS.
Baseline levels of HIV testing and care cascade indicators were heterogeneous between facilities. Per facility, the monthly average number of children/adolescents attending outpatient and inpatient services eligible for HIV testing was 842; on average, 253 received HIV testing services, 6 tested positive, 6 were linked to care, and 5 initiated ART. Among those on treatment at the facility, an average of 15 had a VL sample taken and 13 had suppressed VL results returned. Following the SAIA-PEDS training and mentorship, there was no substantial or significant change in the ratio of HIV testing (RR: 0.803 95% CI: 0.420, 1.532) and linkage to care (RR: 0.831 95% CI: 0.546, 1.266). The ratio of ART initiation increased substantially and trended towards significance (RR: 1.412 95% CI: 0.999, 1.996). There were significant and substantial improvements in the ratio of VL tests ordered (RR: 1.939 95% CI: 1.230, 3.055) but no substantial or significant change in the ratio of VL results suppressed (RR: 0.851 95% CI: 0.554, 1.306).
The piloted SAIA-PEDS implementation strategy was associated with increases in health system performance for indicators later in the HIV care cascade, but not for HIV testing and treatment indicators. This strategy merits further rigorous testing for effectiveness and sustainment.
Great gains were achieved with the introduction of the United Nations' Millennium Development Goals, including improved child survival. Transition to the Sustainable Development Goals (SDGs) focused ...on surviving, thriving, and transforming, representing an important shift to a broader public health goal, the achievement of which holds the promise of longer-term individual and societal benefits. A similar shift is needed with respect to outcomes for infants born to women living with HIV (WLHIV). Programming to prevent vertical HIV transmission has been successful in increasingly achieving a goal of HIV-free survival for infants born to WLHIV. Unfortunately, HIV-exposed uninfected (HEU) children are not achieving comparable health and developmental outcomes compared with children born to HIV-uninfected women under similar socioeconomic circumstances. The 3rd HEU Child Workshop, held as a satellite session of the International AIDS Society's 9th IAS Conference in Paris in July 2017, provided a venue to discuss HEU child health and development disparities. A summary of the Workshop proceedings follows, providing current scientific findings, emphasizing the gap in systems for long-term monitoring, and highlighting the public health need to establish a strategic plan to better quantify the short and longer-term health and developmental outcomes of HEU children.
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