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Kohler P, Agot K, Njuguna IN, Dyer J, Badia J, Jiang W, Beima-Sofie K, Chhun N, Inwani I, Shah SK, Richardson BA, Chaktoura N, John-Stewart G. Data-informed stepped care to improve youth engagement in HIV care in Kenya: a protocol for a cluster randomised trial of a health service intervention. BMJ Open 2022; 12:e062134. [PMID: 36316073 PMCID: PMC9628651 DOI: 10.1136/bmjopen-2022-062134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Adolescents and youth living with HIV (AYLHIV) have lower retention in care, adherence to treatment, and viral suppression compared with adults. Stepped care is a process by which clients are assigned to increasingly intensive services or 'steps' according to level of need. Differentiated care, in which stable clients access less frequent services, can be combined with stepped care to align needs and preferences of youth to promote optimal engagement in care. METHODS AND ANALYSIS This hybrid type I effectiveness implementation cluster randomised trial aims to evaluate a data-informed stepped care (DiSC) intervention for AYLHIV. AYLHIV ages 10-24 receiving care at 24 HIV treatment facilities in Kisumu, Homabay and Migori counties in Kenya will be enrolled. Twelve facilities will be randomised to the DiSC intervention, and 12 will provide standard care. A clinical assignment tool developed by the study team will be used at intervention sites to assign AYLHIV to one of four steps based on risk for loss to follow-up: differentiated care, standard care, counselling services or intensive support services. The primary clinical outcome is retention in care, specifically missed visits (failure to return within 30 days for any visit) and 12-month loss to follow-up. Implementation outcomes are based on the Reach, Effectiveness, Adoption, Implementation and Maintenance framework. Proportions of missed visits will be compared using mixed effect models clustered by facility and participant. ETHICS AND DISSEMINATION This study has been approved by the University of Washington Institutional Review Board (STUDY00011096), Maseno University Ethical Review Committee (MUERC/00917/20) and the Kenya National Commission for Science, Technology and Innovation (444824). AYLHIV provide written informed consent when legally permitted, or assent with caregiver permission for minors. Study staff will work with a Community Advisory Board, including youth members, to disseminate results via discussions, presentations, journal publications and local or international conferences. TRIAL REGISTRATION NUMBER NCT05007717.
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Affiliation(s)
- Pamela Kohler
- Child, Family, and Population Health Nursing, University of Washington, Seattle, Washington, USA
- Global Health, University of Washington, Seattle, Washington, USA
| | - Kawango Agot
- Impact Research and Development Organisation, Kisumu, Kenya
| | - Irene N Njuguna
- Global Health, University of Washington, Seattle, Washington, USA
- Research & Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Jessica Dyer
- Global Health, University of Washington, Seattle, Washington, USA
| | - Jacinta Badia
- Impact Research and Development Organisation, Kisumu, Kenya
| | - Wenwen Jiang
- Epidemiology, University of Washington, Seattle, Washington, USA
| | | | - Nok Chhun
- Global Health, University of Washington, Seattle, Washington, USA
| | - Irene Inwani
- Pediatrics, Kenyatta National Hospital, Nairobi, Kenya
| | - Seema K Shah
- Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Ann and Robert H Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Barbra A Richardson
- Global Health, Biostatistics, University of Washington, Seattle, Washington, USA
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Nahida Chaktoura
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Washington, District of Columbia, USA
| | - Grace John-Stewart
- Global Health, Epidemiology, Pediatrics, Medicine, University of Washington, Seattle, Washington, USA
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Dougherty G, Akoth S, Hawken M, Leting I, Mutei R, Ngugi C, Naitore D, Tsiouris F, Wakoli A, Walker L, Rabkin M. Improving viral load utilisation to enhance care for Kenyan adolescents with HIV. BMJ Open Qual 2022; 11:bmjoq-2022-001900. [PMID: 35948387 PMCID: PMC9379533 DOI: 10.1136/bmjoq-2022-001900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 07/26/2022] [Indexed: 11/04/2022] Open
Abstract
Improving the use of viral load (VL) testing for adolescents and young people living with HIV (AYPLWH) is a priority for Kenya’s Ministry of Health (MOH). Despite expansion of VL testing coverage and rollout of national policies, guidelines and training, VL result utilisation for AYPLWH remains suboptimal, with inadequate adherence to national guidelines recommending everyone on antiretroviral therapy (ART) with unsuppressed viral load (UVL) (≥401 copies/mL) receive three enhanced adherence counselling (EAC) sessions and a repeat VL test within 3 months. In March 2019, ICAP at Columbia University partnered with the MOH to launch a Quality Improvement Collaborative (QIC) at 22 health facilities in the Eastern Province to optimise management of AYPLWH on ART with UVL. Over 17 months, facility QI teams tested interventions targeting client education, workflow modifications, commodity management, community engagement and improved documentation. The QIC led to marked improvement in the proportion of clients completing three EAC sessions and repeat VL testing. Median completion rate was 16% (n=479) at baseline (from March 2018 to February 2019) and rose to 73% (n=755) during the implementation period (from March 2019 to July 2020). In the final month (July 2020), rates rose to 90% (n=31). Another success was the increase in the proportion of clients whose VL was resuppressed on repeat testing, which improved from 34% (n=273) at baseline to 62% (n=710) during the implementation period and 77% (n=44) in the final month. The QIC also led to improvement in the proportion of AYPLWH on first-line ART whose regimens were switched within 2 months of recorded UVL results, which rose from 58% (n=48) at baseline to 94% (n=128) during the implementation period. In summary, the QIC helped facility teams to identify and prioritise local, contextually appropriate innovations which led to swift improvement in three critical indicators of VL utilisation.
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Affiliation(s)
- Gillian Dougherty
- ICAP at Columbia University, Mailman School of Public Health, New York, New York, USA
| | | | | | | | | | | | | | - Fatima Tsiouris
- ICAP at Columbia University, Mailman School of Public Health, New York, New York, USA
| | | | - Lauren Walker
- ICAP at Columbia University, Mailman School of Public Health, New York, New York, USA
| | - Miriam Rabkin
- ICAP at Columbia University, Mailman School of Public Health, New York, New York, USA
- Epidemiology, Columbia University Mailman School of Public Health, New York, New York, USA
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