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Kibel M, Nyambura M, Embleton L, Kiptui R, Galárraga O, Apondi E, Ayuku D, Braitstein P. Enabling Adherence to Treatment (EAT): a pilot study of a combination intervention to improve HIV treatment outcomes among street-connected individuals in western Kenya. BMC Health Serv Res 2023; 23:1331. [PMID: 38037045 PMCID: PMC10691070 DOI: 10.1186/s12913-023-10215-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Accepted: 10/26/2023] [Indexed: 12/02/2023] Open
Abstract
BACKGROUND Street-connected individuals (SCI) in Kenya experience barriers to accessing HIV care. This pilot study provides proof-of-concept for Enabling Adherence to Treatment (EAT), a combination intervention providing modified directly observed therapy (mDOT), daily meals, and peer navigation services to SCI living with HIV or requiring therapy for other conditions (e.g. tuberculosis). The goal of the EAT intervention was to improve engagement in HIV care and viral suppression among SCI living with HIV in an urban setting in Kenya. METHODS This pilot study used a single group, pre/post-test design, and enrolled a convenience sample of self-identified SCI of any age. Participants were able to access free hot meals, peer navigation services, and mDOT 6 days per week. We carried out descriptive statistics to characterize participants' engagement in EAT and HIV treatment outcomes. We used McNemar's chi-square test to calculate unadjusted differences in HIV outcomes pre- and post-intervention among participants enrolled in HIV care prior to EAT. We compared unadjusted time to initiation of antiretroviral therapy (ART) and first episode of viral load (VL) suppression among participants enrolled in HIV care prior to EAT vs. concurrently with EAT using the Wilcoxon rank sum test. Statistical significance was defined as p < 0.05. We calculated total, fixed, and variable costs of the intervention. RESULTS Between July 2018 and February 2020, EAT enrolled 87 participants: 46 (53%) female and 75 (86%) living with HIV. At baseline, 60 out of 75 participants living with HIV (80%) had previously enrolled in HIV care. Out of 60, 56 (93%) had initiated ART, 44 (73%) were active in care, and 25 (42%) were virally suppressed (VL < 1000 copies/mL) at their last VL measure in the 19 months before EAT. After 19 months of follow-up, all 75 participants living with HIV had enrolled in HIV care and initiated ART, 65 (87%) were active in care, and 44 (59%) were virally suppressed at their last VL measure. Among the participants who were enrolled in HIV care before EAT, there was a significant increase in the proportion who were active in HIV care and virally suppressed at their last VL measure during EAT enrollment compared to before EAT enrollment. Participants who enrolled in HIV care concurrently with EAT had a significantly shorter time to initiation of ART and first episode of viral suppression compared to participants who enrolled in HIV care prior to EAT. The total cost of the intervention over 19 months was USD $57,448.64. Fixed costs were USD $3623.04 and variable costs were USD $63.75/month/participant. CONCLUSIONS This pilot study provided proof of concept that EAT, a combination intervention providing mDOT, food, and peer navigation services, was feasible to implement and may support engagement in HIV care and achievement of viral suppression among SCI living with HIV in an urban setting in Kenya. Future work should focus on controlled trials of EAT, assessments of feasibility in other contexts, and cost-effectiveness studies.
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Affiliation(s)
- Mia Kibel
- MD Program, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada.
| | - Monicah Nyambura
- Academic Model Providing Access to Healthcare (AMPATH), P.O. Box 4606-30100, Eldoret, Kenya
| | - Lonnie Embleton
- MD Program, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Department of Global Health and Health System Design, Icahn School of Medicine Mount Sinai, New York, NY, USA
| | - Reuben Kiptui
- Academic Model Providing Access to Healthcare (AMPATH), P.O. Box 4606-30100, Eldoret, Kenya
| | - Omar Galárraga
- Department of Health Services Policy and Practice, and International Health Institute, Brown University School of Public Health, Providence, RI, USA
| | - Edith Apondi
- Academic Model Providing Access to Healthcare (AMPATH), P.O. Box 4606-30100, Eldoret, Kenya
- Department of Child Health and Paediatrics, College of Health Sciences, Moi University, Eldoret, Kenya
| | - David Ayuku
- Department of Mental Health and Behavioral Sciences, School of Medicine, College of Health Sciences, Moi University, Eldoret, Kenya
| | - Paula Braitstein
- MD Program, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Academic Model Providing Access to Healthcare (AMPATH), P.O. Box 4606-30100, Eldoret, Kenya
- Department of Epidemiology and Medical Statistics, School of Public Health, College of Health Sciences, Moi University, Eldoret, Kenya
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Fuseini H, Gyan BA, Kyei GB, Heimburger DC, Koethe JR. Undernutrition and HIV Infection in Sub-Saharan Africa: Health Outcomes and Therapeutic Interventions. Curr HIV/AIDS Rep 2021; 18:87-97. [PMID: 33606196 PMCID: PMC8404370 DOI: 10.1007/s11904-021-00541-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/15/2021] [Indexed: 12/14/2022]
Abstract
PURPOSE OF REVIEW Sub-Saharan Africa (SSA) is disproportionately burdened by the twin epidemics of food insecurity and HIV infection, and protein-calorie undernutrition is common among persons with HIV (PWH) initiating antiretroviral therapy (ART) in the region. In this review, we discuss the intersection of HIV infection and undernutrition, health outcomes among undernourished PWH starting ART, and the demonstrated and potential benefits of therapeutic interventions such as micro/macronutrient supplementation and pharmacological agents. RECENT FINDINGS A low body mass index (BMI), used as a general indicator of poor nutrition in most studies, is associated with impaired immune recovery and increased mortality in the early ART period. The increased risk of mortality is multifactorial, and contributors include undernutrition-related immune system dysfunction, increased susceptibility to opportunistic infections, and metabolic and cardiovascular dysregulation. Clinical trials of micro/macronutrient supplementary feeding, appetite stimulants (hormones and anabolic agents), and recombinant adipokines have shown a benefit for weight gain and metabolic health, but there are few data on mortality or immune recovery. A substantial proportion of PWH in SSA are undernourished, and undernutrition contributes to an increased risk of mortality and other adverse health outcomes. To date, there have been few prospective trials of nutritional supplementation and/or pharmacologic therapy among undernourished PWH in SSA, though findings from other settings suggest a potential benefit in this population.
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Affiliation(s)
- Hubaida Fuseini
- Department of Immunology, Noguchi Memorial Institute for Medical Research, Legon, Ghana.
- Department of Virology, Noguchi Memorial Institute for Medical Research, Legon, Ghana.
- Divison of Infectious Diseases, Vanderbilt University Medical Center, Nashville, TN, 37232-2582, USA.
| | - Ben A Gyan
- Department of Immunology, Noguchi Memorial Institute for Medical Research, Legon, Ghana
- Department of Virology, Noguchi Memorial Institute for Medical Research, Legon, Ghana
| | - George B Kyei
- Department of Immunology, Noguchi Memorial Institute for Medical Research, Legon, Ghana
- Department of Virology, Noguchi Memorial Institute for Medical Research, Legon, Ghana
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, MO, USA
| | | | - John R Koethe
- Divison of Infectious Diseases, Vanderbilt University Medical Center, Nashville, TN, 37232-2582, USA
- Vanderbilt Institute for Global Health, Nashville, TN, USA
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Silverman RA, John-Stewart GC, Beck IA, Milne R, Kiptinness C, McGrath CJ, Richardson BA, Chohan B, Sakr SR, Frenkel LM, Chung MH. Predictors of mortality within the first year of initiating antiretroviral therapy in urban and rural Kenya: A prospective cohort study. PLoS One 2019; 14:e0223411. [PMID: 31584992 PMCID: PMC6777822 DOI: 10.1371/journal.pone.0223411] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Accepted: 09/21/2019] [Indexed: 12/25/2022] Open
Abstract
Introduction Despite increased treatment availability, HIV-infected individuals continue to start antiretroviral therapy (ART) late in disease progression, increasing early mortality risk. Materials and methods Nested prospective cohort study within a randomized clinical trial of adult patients initiating ART at clinics in urban Nairobi and rural Maseno, Kenya, between 2013–2014. We estimated mortality incidence rates following ART initiation and used Cox proportional hazards regression to identify predictors of mortality within 12 months of ART initiation. Analyses were stratified by clinic site to examine differences in mortality correlates and risk by location. Results Among 811 participants initiated on ART, the mortality incidence rate within a year of initiating ART was 7.44 per 100 person-years (95% CI 5.71, 9.69). Among 207 Maseno and 612 Nairobi participants initiated on ART, the mortality incidence rates (per 100 person-years) were 12.78 (95% CI 8.49, 19.23) and 5.72 (95% CI 4.05, 8.09). Maseno had a 2.20-fold greater risk of mortality than Nairobi (95% CI 1.29, 3.76; P = 0.004). This association remained [adjusted hazard ratio (HR) = 2.09 (95% CI 1.17, 3.74); P = 0.013] when adjusting for age, gender, education, pre-treatment drug resistance (PDR), and CD4 count, but not when adjusting for BMI. In unadjusted analyses, other predictors (P<0.05) of mortality included male gender (HR = 1.74), age (HR = 1.04 for 1-year increase), fewer years of education (HR = 0.92 for 1-year increase), unemployment (HR = 1.89), low body mass index (BMI<18.5 m/kg2; HR = 4.99), CD4 count <100 (HR = 11.67) and 100–199 (HR = 3.40) vs. 200–350 cells/μL, and pre-treatment drug resistance (PDR; HR = 2.49). The increased mortality risk associated with older age, males, and greater education remained when adjusted for location, age, education and PDR, but not when adjusted for BMI and CD4 count. PDR remained associated with increased mortality risk when adjusted for location, age, gender, education, and BMI, but not when adjusted for CD4 count. CD4 and BMI associations with increased mortality risk persisted in multivariable analyses. Despite similar baseline CD4 counts across locations, mortality risk associated with low CD4 count, low BMI, and PDR was greater in Maseno than Nairobi in stratified analyses. Conclusions High short-term post-ART mortality was observed, partially due to low CD4 count and BMI at presentation, especially in the rural setting. Male gender, older age, and markers of lower socioeconomic status were also associated with greater mortality risk. Engaging patients earlier in HIV infection remains critical. PDR may influence short-term mortality and further studies to optimize management will be important in settings with increasing PDR.
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Affiliation(s)
- Rachel A. Silverman
- Department of Epidemiology, University of Washington, Seattle, Washington, United States of America
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
- Department of Population Health Sciences, Virginia Polytechnic Institute and State University, Blacksburg, Virginia, United States of America
- * E-mail:
| | - Grace C. John-Stewart
- Department of Epidemiology, University of Washington, Seattle, Washington, United States of America
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
- Department of Medicine, University of Washington, Seattle, Washington, United States of America
- Pediatrics, University of Washington, Seattle, Washington, United States of America
| | - Ingrid A. Beck
- Seattle Children’s Research Institute, Seattle, Washington, United States of America
| | - Ross Milne
- Seattle Children’s Research Institute, Seattle, Washington, United States of America
| | - Catherine Kiptinness
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
| | - Christine J. McGrath
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
| | - Barbra A. Richardson
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
- Department of Biostatistics, University of Washington, Seattle, Washington, United States of America
| | - Bhavna Chohan
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
- Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
| | | | - Lisa M. Frenkel
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
- Department of Medicine, University of Washington, Seattle, Washington, United States of America
- Pediatrics, University of Washington, Seattle, Washington, United States of America
- Seattle Children’s Research Institute, Seattle, Washington, United States of America
- Department of Laboratory Medicine, University of Washington, Seattle, Washington, United States of America
| | - Michael H. Chung
- Department of Epidemiology, University of Washington, Seattle, Washington, United States of America
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
- Department of Medicine, University of Washington, Seattle, Washington, United States of America
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