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Nalubega S, Osuwat LO, Agyeiwaa PB, Evans C, Matovu JB. The practice of pilot/feasibility studies in informing the conduct of HIV related clinical trials in sub-Saharan Africa: A scoping review. Contemp Clin Trials Commun 2022; 29:100959. [PMID: 35865280 PMCID: PMC9294242 DOI: 10.1016/j.conctc.2022.100959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2022] [Revised: 06/21/2022] [Accepted: 06/27/2022] [Indexed: 11/21/2022] Open
Abstract
Introduction Pilot/feasibility studies represent a fundamental phase of the research process and play a vital role in the preliminary planning of a full size HIV clinical trial. Published HIV clinical trial protocols were reviewed to establish the extent to which the proposed HIV clinical trials are informed by a prior pilot/feasibility study. Methods The JBI methodology for scoping reviews was followed. Six databases were systematically searched to identify articles for inclusion. Results Thirty two (32) published HIV study protocols were included. Articles were in the English language and were published in the past 10 years (2011-2020). The review results showed that the majority of HIV-related clinical trials in sub-Saharan Africa were not informed by pilot/feasibility studies. The results further indicated that the number of HIV clinical trials informed by a pilot/feasibility study have been on the increase in the 8 years' period since 2012, a trend that indicates positive uptake of pilot studies in HIV related studies. A few select countries (South Africa, Uganda, Zimbabwe, Malawi and Kenya) comprised more than 70% of all clinical trials that were informed by a pilot/feasibility study, conducted in sub Saharan Africa. Conclusions Although there is an increasing interest among researchers to integrate pilot/feasibility studies in HIV related research, limited countries in sub-Saharan Africa appear to have embraced this trend. Strategies that can motivate researchers to engage in a culture of incorporating pilot/feasibility studies in HIV related research should be implemented.
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Affiliation(s)
- Sylivia Nalubega
- School of Health Sciences, Soroti University, Soroti, Uganda
- Corresponding author. Soroti University, School of Health Sciences, Department of Nursing, Uganda.
| | | | - Poku Brenda Agyeiwaa
- School of Sociology and Socio Policy, University of Nottingham, Nottingham, United Kingdom
| | - Catrin Evans
- School of Health Sciences, University of Nottingham, Nottingham, United Kingdom
- University of Nottingham Center for Evidence Based Healthcare, United Kingdom
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Gaitho D, Kinoti F, Mwaniki L, Kemunto D, Ogoti V, Njigua C, Kubo E, Langat A, Mecha J. Factors associated with the timely uptake of initial HIV virologic test among HIV-exposed infants attending clinics within a faith-based HIV program in Kenya; a cross-sectional study. BMC Public Health 2021; 21:569. [PMID: 33757463 PMCID: PMC7986293 DOI: 10.1186/s12889-021-10587-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Accepted: 03/08/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Early infant diagnosis (EID) of HIV, followed by effective care including antiretroviral therapy (ART), reduces infant mortality by 76% and HIV progression by 75%. In 2015, 50% of 1.2 million HIV-exposed infants (HEI) in 21 priority countries received a virologic test within the recommended 2 months of birth. We sought to identify factors associated with timely uptake of virologic EID among HEI and gain insight into missed opportunities. METHODS This was a cross-sectional study that used de-identified data from electronic medical records of 54 health facilities within the Christian Health Association of Kenya (CHAK) HIV Project database. All HEI who had their first HIV virologic test done between January 2015 and December 2017 were included in the study and categorized as either having the test within or after 8 weeks of birth. Multivariate linear mixed effects regression model was used to determine factors associated with uptake of the first HIV EID polymerase chain reaction (PCR). Predictor variables studied include sex, birth weight, the entry point into care, provision of ART prophylaxis for the infant, maternal ART at time of EID, mode of delivery, and place of delivery. RESULTS We included 2020 HEI of whom 1018 (50.4%) were female. A majority, 1596 (79.0%) had their first HIV PCR within 2 months of birth at a median age of 6.4 weeks (interquartile range 6-7.4). Overall, HIV positivity rate at initial test among this cohort was 1.2%. Delayed HIV PCR testing for EID was more likely to yield a positive result [adjusted odds ratio (aOR) = 1.29 (95% confidence interval (CI) 1.09-1.52) p = 0.003]. Infants of mothers not on ART at the time of HIV PCR test and infants who had not received prophylaxis to prevent vertical HIV transmission had significant increased odds of a delayed initial test [aOR = 1.27 (95% CI = 1.18-1.37) p = < 0.0001] and [aOR = 1.43 (95% CI 1.27-1.61) p = < 0.001] respectively. CONCLUSION An initial HIV PCR test done after 8 weeks of birth is likely to yield a positive result. Barriers to accessing ART for treatment among HIV-infected pregnant and breastfeeding women, and prophylaxis for the HEI were associated with delayed EID. In order to ensure timely EID, programs need to incorporate both facility and community strategy interventions to ensure all pregnant women seek antenatal care and deliver within health facilities.
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Affiliation(s)
- Douglas Gaitho
- Christian Health Association of Kenya (CHAK), P.O. Box 30690 – 00100, GPO, Nairobi, Kenya
| | - Freda Kinoti
- Department of Clinical Medicine & Therapeutics, University of Nairobi, P.O. Box 19676 – 00202, Nairobi, Kenya
| | - Lawrence Mwaniki
- Christian Health Association of Kenya (CHAK), P.O. Box 30690 – 00100, GPO, Nairobi, Kenya
| | - Diana Kemunto
- Christian Health Association of Kenya (CHAK), P.O. Box 30690 – 00100, GPO, Nairobi, Kenya
| | - Victor Ogoti
- Christian Health Association of Kenya (CHAK), P.O. Box 30690 – 00100, GPO, Nairobi, Kenya
| | - Catherine Njigua
- Christian Health Association of Kenya (CHAK), P.O. Box 30690 – 00100, GPO, Nairobi, Kenya
| | - Elizabeth Kubo
- Christian Health Association of Kenya (CHAK), P.O. Box 30690 – 00100, GPO, Nairobi, Kenya
| | - Agnes Langat
- Division of Global HIV and TB, Centers for Disease Control and Prevention Kenya, P.O. Box 606 – 00621, Village Market, Nairobi, Kenya
| | - Jared Mecha
- Department of Clinical medicine & Therapeutics, College of Health Sciences – University of Nairobi, P.O. Box 19676 – 00202, Nairobi, Kenya
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Wexler C, Nazir N, Gautney B, Maloba M, Brown M, Goggin K, Lwembe R, Finocchario-Kessler S. Predictors of Early ART Initiation Among HIV + Infants in Kenya: A Retrospective Review of HITSystem Data from 2013 to 2017. Matern Child Health J 2021; 24:739-747. [PMID: 32285335 DOI: 10.1007/s10995-020-02909-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Early initiation of antiretroviral therapy (ART, before 12 weeks of age) among infants living with HIV reduces infant mortality and slows disease progression. However, inefficiencies in early infant diagnosis processes prevents timely ART initiation among infants living with HIV in Kenya. This study assesses predictors of early ART initiation among infants living with HIV in Kenya. DESIGN We retrospectively reviewed data from 96 infants living with HIV born between January 2013 and June 2017 at 6 Kenyan government hospitals. METHODS The primary outcome was infant receipt of ART by 12 weeks of age. We assessed bivariable and multivariable predictors of ART initiation by 12 weeks of age. RESULTS Among 96 infants living with HIV, 82 (85.4%) infants initiated ART at a median infant age of 17.1 weeks. Of the 82 infants who started ART, only 17 (20.7%) initiated ART by 12 weeks of age. In multivariable logistic regression analyses, testing per national guidelines (< 7 weeks of age) (aOR 40.14 [3.96-406.97], p = 0.002), shorter turnaround time for result notification (≤ 4 weeks) (aOR 11.30 [2.02-63.34], p = 0.006), and ART initiation within 3 days of mother notification (aOR 7.32 [1.41-38.03], p = 0.006) were significantly associated with ART initiation by 12 weeks of age. CONCLUSION Current implementation of early infant diagnosis services in Kenyan only achieves targets for early ART initiation in one-fifth of infants with HIV. Strengthening services to support earlier infant testing and streamlined processes for early infant diagnosis may increase the proportion of infants who receive timely ART.
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Affiliation(s)
- Catherine Wexler
- Department of Family Medicine, University of Kansas Medical Center, 3901 Rainbow Blvd., Kansas City, KS, 66160, USA.
| | - Niaman Nazir
- Department of Preventive Medicine and Public Health, University of Kansas Medical Center, Kansas City, KS, USA
| | | | - May Maloba
- Global Health Innovations, Nairobi, Kenya
| | - Melinda Brown
- Department of Family Medicine, University of Kansas Medical Center, 3901 Rainbow Blvd., Kansas City, KS, 66160, USA
| | - Kathy Goggin
- Health Services and Outcomes Research, Children's Mercy Kansas City, Kansas City, MO, USA.,University of Missouri- Kansas City School of Medicine, Kansas City, MO, USA
| | - Raphael Lwembe
- Center for Virus Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Sarah Finocchario-Kessler
- Department of Family Medicine, University of Kansas Medical Center, 3901 Rainbow Blvd., Kansas City, KS, 66160, USA
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4
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Hurley EA, Odeny B, Wexler C, Brown M, MacKenzie A, Goggin K, Maloba M, Gautney B, Finocchario-Kessler S. "It was my obligation as mother": 18-Month completion of Early Infant Diagnosis as identity control for mothers living with HIV in Kenya. Soc Sci Med 2020; 250:112866. [PMID: 32145483 DOI: 10.1016/j.socscimed.2020.112866] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Revised: 12/31/2019] [Accepted: 02/16/2020] [Indexed: 12/26/2022]
Abstract
RATIONALE Early Infant Diagnosis (EID) is critical to timely identification of HIV and rapid treatment initiation for infants found to be infected. Completing the EID cascade involves a series of age-specific tests between birth and 18 months and can be challenging for mother- infant pairs in low-resource settings. Even prior to recent increases in Kenya's testing recommendations, approximately 22% of mother-infant pairs enrolled in EID were lost to follow-up. As EID cascades become increasingly complex, identifying strategies to maximize retention becomes even more essential. Despite ongoing health system improvements, we still lack a framework for understanding the individual-level, psychosocial processes underlying EID completion-insight that could be essential for shaping strategies to support patients and close gaps in retention. OBJECTIVE Our objective was to explain individual-level processes that lead to EID completion among mothers who successfully completed the EID cascade. METHODS Using qualitative methods informed by grounded theory, we conducted 65 interviews with Kenyan mothers who completed EID. RESULTS We identified three themes related to completion: (1) Negative motivation, from the consequences of infant infection, fear of postnatal transmission, and burden of maternal failure; (2) Positive motivation, from achieving a final goal, responding to provider support, and maximizing infant health; and (3) Overcoming challenges, through resolve/resiliency, planning/privatizing and rejecting stigma/leveraging support. CONCLUSION Overall, the EID cascade served as a framing process for women to secure an identity as a good mother. Successful EID completion was the product of a strong motivational foundation channeled into strategies to surmount persistent challenges. Participant accounts of overcoming challenges highlight their resiliency as well as the outstanding need to address financial, logistical, and social barriers to care. Future EID programs may capitalize on these findings by affirming patients' quest for identity control, leveraging positive motivators, and expanding peer support structures to help mothers feel connected throughout the cascade.
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Affiliation(s)
- Emily A Hurley
- Children's Mercy Kansas City, Health Services and Outcomes Research, Kansas City, MO, USA.
| | - Beryne Odeny
- University of Washington School of Public Health, Department of Global Health, Seattle, WA, USA
| | - Catherine Wexler
- University of Kansas Medical Center, Department of Family Medicine, Kansas City, KS, USA
| | - Melinda Brown
- University of Kansas Medical Center, Department of Family Medicine, Kansas City, KS, USA
| | - Alexander MacKenzie
- Children's Mercy Kansas City, Health Services and Outcomes Research, Kansas City, MO, USA
| | - Kathy Goggin
- Children's Mercy Kansas City, Health Services and Outcomes Research, Kansas City, MO, USA; University of Missouri-Kansas City, School of Medicine, Kansas City, MO, USA; University of Missouri-Kansas City, School of Pharmacy, Kansas City, MO, USA
| | - May Maloba
- Global Health Innovations, Nairobi, Kenya
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Predictors of Mortality Among HIV-exposed Infants Through 18 Months of Age in Kenya: A Retrospective Review of Programmatic Data. Pediatr Infect Dis J 2020; 39:134-136. [PMID: 31738324 DOI: 10.1097/inf.0000000000002511] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
We identified mortality predictors among HIV-exposed uninfected infants and infants living with HIV in Kenyan early infant diagnosis services between 2012 and 2017. Younger maternal age and absence of antenatal antiretroviral therapy among HIV-exposed uninfected infants (n = 2366) and travel time to hospital and delayed infant testing among infants living with HIV (n = 130) predicted mortality, highlighting the importance of supporting engagement in maternal/pediatric HIV services.
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Brown M, Wexler C, Gautney B, Goggin K, Hurley EA, Odeny B, Maloba M, Lwembe R, Sandbulte M, Finocchario-Kessler S. eHealth Interventions for Early Infant Diagnosis: Mothers' Satisfaction with the HIV Infant Tracking System in Kenya. AIDS Behav 2019; 23:3093-3102. [PMID: 31313093 DOI: 10.1007/s10461-019-02579-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The HIV Infant Tracking System (HITSystem) is an eHealth intervention to improve early infant diagnosis (EID) through alerts to providers and text messages to mothers. This study explored mothers' experiences receiving standard and HITSystem-enhanced EID services to assess perceived intervention benefits, acceptability, and opportunities for improvement. This qualitative study was embedded within a cluster-randomized control trial to evaluate the HITSystem at six Kenyan government hospitals (3 intervention, 3 control). We conducted semi-structured interviews with 137 mothers attending EID follow-up visits. Compared to control sites, participants at HITSystem sites described enhanced EID quality; HITSystem-generated texts informed them of result availability and retesting needs, provided cues-to-action for clinic attendance, and engendered opportunities for patient support. They described improved EID efficiency through shorter waiting periods for results and fewer hospital visits. Participants reported high satisfaction with EID and acceptability of text messages; however, modifications to ensure text delivery, increase repeat testing reminders, include low literacy content options, and provide encouraging messages were suggested. These user experience data suggest improvements in EID at HITSystem sites when compared with control sites.
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Affiliation(s)
- Melinda Brown
- Department of Family Medicine, University of Kansas Medical Center, 3901 Rainbow Blvd., Kansas City, KS, 66160, USA.
| | - Catherine Wexler
- Department of Family Medicine, University of Kansas Medical Center, 3901 Rainbow Blvd., Kansas City, KS, 66160, USA
| | | | - Kathy Goggin
- Health Services and Outcomes Research, Children's Mercy Kansas City, Kansas City, MO, USA
- Schools of Medicine and Pharmacy, University of Missouri-Kansas City, Kansas City, MO, USA
| | - Emily A Hurley
- Health Services and Outcomes Research, Children's Mercy Kansas City, Kansas City, MO, USA
| | - Beryne Odeny
- Department of Family Medicine, University of Kansas Medical Center, 3901 Rainbow Blvd., Kansas City, KS, 66160, USA
- Global Health Innovations, Dallas, TX, USA
| | - May Maloba
- Global Health Innovations, Nairobi, Kenya
| | - Raphael Lwembe
- Centre for Virus Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Matthew Sandbulte
- Department of Family Medicine, University of Kansas Medical Center, 3901 Rainbow Blvd., Kansas City, KS, 66160, USA
| | - Sarah Finocchario-Kessler
- Department of Family Medicine, University of Kansas Medical Center, 3901 Rainbow Blvd., Kansas City, KS, 66160, USA
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7
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Goggin K, Hurley EA, Staggs VS, Wexler C, Nazir N, Gautney B, Khamadi SA, Maloba M, Lwembe R, Finocchario-Kessler S. Rates and Predictors of HIV-Exposed Infants Lost to Follow-Up During Early Infant Diagnosis Services in Kenya. AIDS Patient Care STDS 2019; 33:346-353. [PMID: 31369296 DOI: 10.1089/apc.2019.0050] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Early infant diagnosis (EID) involves age-specific tracking and testing of HIV-exposed infants during the first 18 months of life and rapid initiation of life-saving treatment for those infected. In Kenya, pre-2013 data estimate EID lost to follow-up (LTFU) at 39-65%, yet no study has documented LTFU rates and predictors throughout the EID cascade since Option B+ fundamentally changed services by placing all HIV-positive expectant mothers on lifelong treatment. Using an explanatory mixed-method design, we assessed LTFU rates and predictors among 870 mother-infant dyads enrolled in EID in six urban/peri-urban Kenyan government hospitals. Mothers completed baseline surveys, and dyads were tracked through EID. We selected 12 baseline variables and modeled odds of LTFU at 9 and 18 months using mixed logistic regression. Qualitative interviews were conducted with 61 mothers to assess barriers and facilitators to completing EID. Thematically coded transcripts were used to interpret quantitative predictors of LTFU. By the 18-month test, 145 dyads (22%) were LTFU, with three-quarters of LTFU occurring between 9- and 18-month tests. Odds of LTFU at 18 months decreased by 10% for each additional year of maternal age and by 66% with HIV status disclosure. Qualitative data revealed how disclosure facilitated essential social support for EID completion and how older mothers attributed maturity and life experience to successful engagement in care. Findings suggest LTFU rates in Kenya have declined, but gaps remain in ensuring universal coverage. Efforts to improve retention should focus on increasing support for younger mothers and those who have not disclosed their HIV status.
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Affiliation(s)
- Kathy Goggin
- Division of Health Services and Outcomes Research, Children's Mercy Kansas City, Kansas City, Missouri
- School of Medicine and University of Missouri-Kansas City, Kansas City, Missouri
- School of Pharmacy, University of Missouri-Kansas City, Kansas City, Missouri
| | - Emily A. Hurley
- Division of Health Services and Outcomes Research, Children's Mercy Kansas City, Kansas City, Missouri
| | - Vincent S. Staggs
- Division of Health Services and Outcomes Research, Children's Mercy Kansas City, Kansas City, Missouri
- School of Medicine and University of Missouri-Kansas City, Kansas City, Missouri
- Biostatistics and Epidemiology Core, Children's Mercy Kansas City, Kansas City, Missouri
| | - Catherine Wexler
- Department of Family Medicine and University of Kansas Medical Center, Kansas City, Missouri
| | - Niaman Nazir
- Department of Preventive Medicine, University of Kansas Medical Center, Kansas City, Missouri
| | | | | | - May Maloba
- Global Health Innovations, Dallas, Texas
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8
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Finocchario-Kessler S, Maloba M, Brown M, Gautney B, Goggin K, Wexler C, Mabachi N, Odeny B, Lagat S, Koech S, Dariotis JK, Odeny TA. Adapting the HIV Infant Tracking System to Support Prevention of Mother-to-Child Transmission of HIV in Kenya: Protocol for an Intervention Development Pilot Study in Two Hospitals. JMIR Res Protoc 2019; 8:e13268. [PMID: 31199305 PMCID: PMC6592400 DOI: 10.2196/13268] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Revised: 04/16/2019] [Accepted: 04/16/2019] [Indexed: 01/10/2023] Open
Abstract
Background Despite progress to expand access to HIV testing and treatment during pregnancy in Kenya, gaps still remain in prevention of mother-to-child transmission of HIV (PMTCT) services. This study addresses the need for effective and scalable interventions to support women throughout the continuum of care for PMTCT services in low-resource settings. Our research team has successfully implemented the HIV Infant Tracking System (HITSystem), a Web-based, system-level intervention to improve early infant diagnosis (EID) outcomes. Objective This study will expand the scope of the HITSystem to address PMTCT services to bridge the gap between maternal and pediatric HIV services and improve outcomes. This paper describes the intervention development protocol to adapt and pilot an HITSystem version 2.0 to assess acceptability, feasibility, and preliminary PMTCT outcomes in Kenya. Methods This is a 3-year intervention development study to adapt the current HITSystem intervention to support a range of PMTCT outcomes including appointment attendance, antiretroviral therapy (ART) adherence, hospital deliveries, and integration of maternal and pediatric HIV services in low-resource settings. The study will be conducted in 3 phases. Phase 1 will elicit feedback from intervention users (patients and providers) to guide development and refinement of the new PMTCT components and inform optimal implementation. In Phase 2, we will design and develop the HITSystem 2.0 features to support key PMTCT outcomes guided by clinical content experts and findings from Phase 1. Phase 3 will assess complete PMTCT retention (before, during, and after delivery) using a matched randomized pilot study design in 2 hospitals over 18 months. A total of N=108 HIV-positive pregnant women (n=54 per site) will be enrolled and followed from their first PMTCT appointment until infant HIV DNA Polymerase Chain Reaction testing at the target age of 6 weeks (<7 weeks) postnatal. Results Funding for this study was received in August 2015, enrollment in Phase 1 began in March 2016, and completion of data collection is expected by May 2019. Conclusions This protocol will extend, adapt, and pilot an HITSystem 2.0 version to improve attendance of PMTCT appointments, increase ART adherence and hospital-based deliveries, and prompt EID by 6 weeks postnatal. The HITSystem 2.0 aims to improve the integration of maternal and pediatric HIV services. Trial Registration ClinicalTrials.gov NCT02726607; https://clinicaltrials.gov/ct2/show/NCT02726607 (Archived by WebCite at http://www.webcitation.org/78VraLrOb) International Registered Report Identifier (IRRID) DERR1-10.2196/13268
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Affiliation(s)
| | - May Maloba
- Global Health Innovations, Nairobi, Kenya
| | - Melinda Brown
- Department of Family Medicine, University of Kansas Medical Center, Kansas City, KS, United States
| | - Brad Gautney
- Global Health Innovations, Dallas, TX, United States
| | - Kathy Goggin
- School of Medicine, University of Missouri-Kansas City, Kansas City, MO, United States.,Health Services and Outcomes Research, Children's Mercy Kansas City, Kansas City, MO, United States.,School of Pharmacy, University of Missouri-Kansas City, Kansas City, MO, United States
| | - Catherine Wexler
- Department of Family Medicine, University of Kansas Medical Center, Kansas City, KS, United States
| | - Natabhona Mabachi
- Department of Family Medicine, University of Kansas Medical Center, Kansas City, KS, United States
| | - Beryne Odeny
- Department of Family Medicine, University of Kansas Medical Center, Kansas City, KS, United States
| | - Silas Lagat
- Ministry of Health, Nandi County, Kapsabet, Kenya
| | - Sharon Koech
- Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Jacinda K Dariotis
- College of Education, Criminal Justice & Human Services, University of Cincinnati, Cincinnati, OH, United States
| | - Thomas A Odeny
- School of Medicine, University of Missouri-Kansas City, Kansas City, MO, United States.,Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
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9
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Sandbulte MR, Gautney BJ, Maloba M, Wexler C, Brown M, Mabachi N, Goggin K, Lwembe R, Nazir N, Odeny TA, Finocchario-Kessler S. Infant HIV testing at birth using point-of-care and conventional HIV DNA PCR: an implementation feasibility pilot study in Kenya. Pilot Feasibility Stud 2019; 5:18. [PMID: 30701079 PMCID: PMC6347792 DOI: 10.1186/s40814-019-0402-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Accepted: 01/11/2019] [Indexed: 12/03/2022] Open
Abstract
Background Infant HIV diagnosis by HIV DNA polymerase chain reaction (PCR) testing at the standard 6 weeks of age is often late to mitigate the mortality peak that occurs in HIV positive infants’ first 2–3 months of life. Kenya recently revised their early infant diagnosis (EID) guidelines to include HIV DNA PCR testing at birth (pilot only), 6 weeks, 6 months, and 12 months postnatal and a final 18-month antibody test. The World Health Organization (WHO) approved point-of-care (POC) diagnostic platforms for infant HIV testing in resource-limited countries that could simplify logistics and expedite infant diagnosis. Sustainable scale-up and optimal utility in Kenya and other high-prevalence countries depend on robust implementation studies in diverse clinical settings. Methods We will pilot the implementation of birth testing by HIV DNA PCR, as well as two POC testing systems (Xpert HIV-1 Qual [Xpert] and Alere q HIV-1/2 Detect [Alere q]), on specimens collected from Kenyan infants at birth (0 to 2 weeks) and 6 weeks (4 to < 24 weeks) postnatal. The formative phase will inform optimal implementation of birth testing and two POC testing technologies. Qualitative interviews with stakeholders (providers, parents of HIV-exposed infants, and community members) will assess attitudes, barriers, and recommendations to optimize implementation at their respective sites. A non-blinded pilot study at four Kenyan hospitals (n = 2 Xpert, n = 2 Alere q platforms) will evaluate infant HIV POC testing compared with standard of care HIV DNA PCR testing in both the birth and 6-week windows. Objectives of the pilot are to assess uptake, efficiency, quality, implementation variables, user experiences of birth testing with both POC testing systems or with HIV DNA PCR, and costs. Discussion This study will generate data on the clinical impact and feasibility of adding HIV testing at birth utilizing POC and traditional PCR HIV testing strategies in resource-limited settings. Data from this pilot will inform the optimal implementation of Kenya’s birth testing guidelines and of POC testing systems for the improvement of EID outcomes. Trial registration ClinicalTrials.gov, NCT03435887. Registered 26 February 2018. Electronic supplementary material The online version of this article (10.1186/s40814-019-0402-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Matthew R Sandbulte
- 1Department of Family Medicine, University of Kansas Medical Center, Kansas City, KS USA
| | | | - May Maloba
- Global Health Innovations, Nairobi, Kenya
| | - Catherine Wexler
- 1Department of Family Medicine, University of Kansas Medical Center, Kansas City, KS USA
| | - Melinda Brown
- 1Department of Family Medicine, University of Kansas Medical Center, Kansas City, KS USA
| | - Natabhona Mabachi
- 1Department of Family Medicine, University of Kansas Medical Center, Kansas City, KS USA
| | - Kathy Goggin
- 4Health Services and Outcomes Research, Children's Mercy Hospitals and Clinics, Kansas City, MO USA.,5University of Missouri-Kansas City School of Medicine, Kansas City, MO USA
| | - Raphael Lwembe
- 6Centre for Virus Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Niaman Nazir
- 7Department of Preventive Medicine and Public Health, University of Kansas Medical Center, Kansas City, KS USA
| | - Thomas A Odeny
- 5University of Missouri-Kansas City School of Medicine, Kansas City, MO USA.,8Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
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10
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Finocchario-Kessler S, Gautney B, Cheng A, Wexler C, Maloba M, Nazir N, Khamadi S, Lwembe R, Brown M, Odeny TA, Dariotis JK, Sandbulte M, Mabachi N, Goggin K. Evaluation of the HIV Infant Tracking System (HITSystem) to optimise quality and efficiency of early infant diagnosis: a cluster-randomised trial in Kenya. Lancet HIV 2018; 5:e696-e705. [PMID: 30309787 PMCID: PMC6289743 DOI: 10.1016/s2352-3018(18)30245-5] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Revised: 08/17/2018] [Accepted: 08/31/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND The HIV Infant Tracking System (HITSystem) is a web-based intervention linking providers of early infant diagnosis, laboratory technicians, and mothers and infants to improve outcomes for HIV-exposed infants. We aimed to evaluate the efficacy of the HITSystem on key outcomes of early infant diagnosis. METHODS We did a cluster-randomised trial at six hospitals in Kenya, which were matched on geographic region, resource level, and volume of patients (high, medium, and low). We randomly allocated hospitals within a matched pair to either the HITSystem (intervention; n=3) or standard of care (control; n=3). A random number generator was used to assign clusters. Investigators were unaware of the randomisation process. Eligible participants were mothers aged 18 years or older with an infant younger than 24 weeks presenting for their first early infant diagnosis appointment. The primary outcome was complete early infant diagnosis retention, which was defined as receipt of all indicated age-specific interventions until 18 months post partum (for HIV-negative infants) or antiretroviral therapy initiation (for HIV-positive infants). Analysis was per protocol in all randomised pairs judged eligible, excluding infant deaths and those who moved or were transferred to another health facility. Modified intention-to-treat sensitivity analyses judged all infant deaths and transfers as incomplete early infant diagnosis retention. Separate multivariable logistic regression analyses were done with intervention group, hospital volume, and significant covariates as fixed effects. This trial is registered with ClinicalTrials.gov, number NCT02072603; the trial has been completed. FINDINGS Between Feb 16, 2014, and Dec 31, 2015, 895 mother-infant pairs were enrolled. Of these, 87 were judged ineligible for analysis, 26 infants died, and 92 pairs moved or were transferred to another health facility. Thus, data from 690 mother-infant pairs were analysed, of whom 392 were allocated to the HITSystem and 298 to standard of care. Mother-infant pairs were followed up to Sept 30, 2017. Infants diagnosed as HIV-positive were followed up for a median of 2·1 months (IQR 1·6-4·8) and HIV-negative infants were followed up for a median of 17·0 months (IQR 16·6-17·6). Infants enrolled in the HITSystem were significantly more likely to receive complete early infant diagnosis services compared with those assigned standard of care (334 of 392 [85%] vs 180 of 298 [60%]; adjusted odds ratio [OR] 3·7, 95% CI 2·5-5·5; p<0·0001). No intervention effect was recorded at high-volume hospitals, but strong effects were seen at medium-volume and low-volume hospitals. Modified intention-to-treat analyses for complete early infant diagnosis were also significant (334 of 474 [70%] vs 180 of 334 [54%]; adjusted OR 2·0, 95% CI 1·4-2·7; p<0·0001). No adverse events related to study participation were reported. INTERPRETATION The HITSystem intervention is effective and feasible to implement in low-resource settings. The HITSystem algorithms have been modified to include HIV testing at birth, and an adapted HITSystem 2.0 version is supporting HIV-positive pregnant women to prevent perinatal transmission and optimise maternal and infant outcomes. FUNDING National Institute of Child Health and Human Development.
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Affiliation(s)
| | | | - AnLin Cheng
- University of Missouri-Kansas City, School of Medicine, Kansas City, MO, USA
| | - Catherine Wexler
- Department of Family Medicine, University of Kansas Medical Center, Kansas City, KS, USA
| | - May Maloba
- Global Health Innovations, Nairobi, Kenya
| | - Niaman Nazir
- Department of Preventive Medicine, University of Kansas Medical Center, Kansas City, KS, USA
| | - Samoel Khamadi
- Center for Virus Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Raphael Lwembe
- Center for Virus Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Melinda Brown
- Department of Family Medicine, University of Kansas Medical Center, Kansas City, KS, USA
| | - Thomas A Odeny
- University of Missouri-Kansas City, School of Medicine, Kansas City, MO, USA; Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Jacinda K Dariotis
- College of Education, Criminal Justice, and Human Services, University of Cincinatti, Cincinatti, OH, USA
| | - Matthew Sandbulte
- Department of Family Medicine, University of Kansas Medical Center, Kansas City, KS, USA
| | - Natabhona Mabachi
- Department of Family Medicine, University of Kansas Medical Center, Kansas City, KS, USA
| | - Kathy Goggin
- University of Missouri-Kansas City, School of Medicine, Kansas City, MO, USA; Children's Mercy Kansas City, Health Services and Outcomes Research, Kansas City, MO, USA
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11
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Wexler C, Brown M, Hurley EA, Ochieng M, Goggin K, Gautney B, Maloba M, Lwembe R, Khamadi S, Finocchario-Kessler S. Implementing eHealth Technology to Address Gaps in Early Infant Diagnosis Services: Qualitative Assessment of Kenyan Provider Experiences. JMIR Mhealth Uhealth 2018; 6:e169. [PMID: 30135052 PMCID: PMC6125609 DOI: 10.2196/mhealth.9725] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Revised: 04/27/2018] [Accepted: 06/21/2018] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Literature suggests that electronic health (eHealth) interventions can improve the efficiency and accuracy of health service delivery and improve health outcomes and are generally well received by patients; however, there are limited data on provider experiences using eHealth interventions in resource-limited settings. The HIV Infant Tracking System (HITSystem) is an eHealth intervention designed to improve early infant diagnosis (EID) outcomes among HIV-exposed infants. OBJECTIVE We aimed to compare provider experiences with standard EID and HITSystem implementation at 6 Kenyan hospitals and 3 laboratories. The objective of this study was to better understand provider experiences implementing and using the HITSystem in order to assess facilitators and barriers that may impact adoption and sustainability of this eHealth intervention. METHODS As part of a randomized controlled trial to evaluate the HITSystem, we conducted semistructured interviews with 17 EID providers at participating intervention and control hospitals and laboratories. RESULTS Providers emphasized the perceived usefulness of the HITSystem, including improved efficiency in sample tracking and patient follow-up, strengthened communication networks among key stakeholders, and improved capacity to meet patient needs compared to standard EID. These advantages were realized from an intervention that providers saw as easy to use and largely compatible with workflow. However, supply stock outs and patient psychosocial factors (including fear of HIV status disclosure and poverty) provided ongoing challenges to EID service provision. Furthermore, slow or sporadic internet access and heavy workload prevented real-time HITSystem data entry for some clinicians. CONCLUSIONS Provider experiences with the HITSystem indicate that the usefulness of the HITSystem, along with the ease with which it is able to be incorporated into hospital workflows, contributes to its sustained adoption and use in Kenyan hospitals. To maximize implementation success, care should be taken in intervention design and implementation to ensure that end users see clear advantages to using the technology and to account for variations in workflows, patient populations, and resource levels by allowing flexibility to suit user needs. TRIAL REGISTRATION ClinicalTrials.gov NCT02072603; https://clinicaltrials.gov/ct2/show/NCT02072603 (Archived by WebCite at http://www.webcitation.org/71NgMCrAm).
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Affiliation(s)
- Catherine Wexler
- Department of Family Medicine, University of Kansas Medical Center, Kansas City, KS, United States
| | - Melinda Brown
- Department of Family Medicine, University of Kansas Medical Center, Kansas City, KS, United States
| | - Emily A Hurley
- Health Services and Outcomes Research, Children's Mercy Kansas City, Kansas City, MO, United States
| | | | - Kathy Goggin
- Health Services and Outcomes Research, Children's Mercy Kansas City, Kansas City, MO, United States
- School of Medicine, University of Missouri-Kansas City, Kansas City, MO, United States
- School of Pharmacy, University of Missouri-Kansas City, Kansas City, MO, United States
| | - Brad Gautney
- Global Health Innovations, Dallas, TX, United States
| | - May Maloba
- Global Health Innovations, Dallas, TX, United States
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Abrams EJ, Ananworanich J, Archary M, Ngongondo M, Brouwers P. Propelling the Pediatric HIV Therapeutic Agenda With Science, Innovation, and Collaboration. J Acquir Immune Defic Syndr 2018; 78 Suppl 1:S32-S39. [PMID: 29994918 PMCID: PMC6044456 DOI: 10.1097/qai.0000000000001747] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND A number of well-described obstacles to the pediatric therapeutic agenda have resulted in substantial delays in the introduction of new medications, formulations, strategies, and approaches to treat infants, children, and adolescents living with HIV. SETTING Global landscape. METHODS The authors will provide a summary of current and emerging initiatives to accelerate the pediatric therapeutic agenda including illustrative case studies of innovations and scientific discovery in diagnosis and treatment of very young children with HIV infection. RESULTS The challenges posed by rapid physiologic and developmental changes that characterize the trajectory of childhood as well as the complex regulatory and fiscal milieu of HIV therapeutics have hampered pediatric HIV therapeutic research. Recent efforts to accelerate this agenda include prioritizing agents and formulations, defining dosing by weight bands, applying innovative study designs, synergizing work across research networks to achieve common goals, and the establishment of a global prioritized research agenda. A case study of initiatives to diagnose and effectively treat newborns and infants will illustrate the critical role of basic science research and novel approaches to study design and implementation that are informing global efforts to end AIDS. CONCLUSIONS A pediatric therapeutic agenda informed by basic science and achieved through innovation and global cooperation is essential to achieve an AIDS-free generation.
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Affiliation(s)
- Elaine J. Abrams
- ICAP at Columbia, Mailman School of Public Health, College of Physicians & Surgeons, Columbia University, New York, NY
| | - Jintanat Ananworanich
- US Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, MD
- Henry M Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD
- Department of Global Health, University of Amsterdam, Amsterdam, the Netherlands
| | - Moherndran Archary
- Paediatric Infectious Diseases Unit, King Edward VIII Hospital, University of KwaZulu Natal, Durban, South Africa
| | | | - Pim Brouwers
- Division of AIDS Research, National Institute of Mental Health, National Institutes of Health, Bethesda, MD
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13
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Abstract
PURPOSE OF REVIEW The goal of this paper is to describe areas in prevention of mother-to-child transmission of HIV (PMTCT) programs that could benefit from ehealth and to summarize current evidence of ehealth effectiveness in PMTCT. RECENT FINDINGS PMTCT programs require maternal retention, adherence to antiretroviral treatment (ART), and return for infant diagnosis of HIV. eHealth systems for PMTCT could either be integrated within MCH ehealth systems or within HIV adherence ehealth systems. PMTCT ehealth messages need to balance maternal concerns about pregnancy, childbirth, and infant care with need for clinic retention and ART adherence for PMTCT. Health approaches currently being assessed for effects on PMTCT outcomes include SMS, phone reminders, and integration of laboratory results and health worker reminders. Randomized trials are ongoing to determine effect of PMTCT ehealth interventions on retention, adherence, viral suppression, and early infant diagnosis (EID). There is evidence that ehealth for PMTCT improves early retention and EID, while data on long-term outcomes are accruing. PMTCT ehealth interventions may be useful to enhance maternal retention and ART adherence and decrease risk of infant HIV infection. Ongoing clinical trials will be important to determine effectiveness of mhealth approaches in improving PMTCT outcomes.
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Affiliation(s)
- Grace John-Stewart
- Departments of Global Health, Epidemiology, Medicine, and Pediatrics, University of Washington, Seattle, WA, USA.
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Pilgrim NA, Okal J, Matheka J, Mukui I, Kalibala S. Challenges to and opportunities for the adoption and routine use of early warning indicators to monitor pediatric HIV drug resistance in Kenya. BMC Pediatr 2018; 18:243. [PMID: 30045700 PMCID: PMC6060498 DOI: 10.1186/s12887-018-1209-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Accepted: 07/03/2018] [Indexed: 11/11/2022] Open
Abstract
Background Pediatric non-adherence to antiretroviral therapy (ART), loss to follow-up, and HIV drug resistance (HIVDR) are challenges to achieving UNAIDS’ targets of 90% of those diagnosed HIV-positive receiving treatment, and 90% of those receiving treatment achieving viral suppression. In Kenya, the pediatric population represents 8% of total HIV infections and pediatric virological failure is estimated at 33%. The monitoring of early warning indicators (EWIs) for HIVDR can help to identify and correct gaps in ART program functioning to improve HIV care and treatment outcomes. However, EWIs have not been integrated into health systems. We assessed challenges to the use of EWIs and solutions to challenges identified by frontline health administrators. Methods We conducted key informant interviews with health administrators who were fully knowledgeable of the ART program at 23 pediatric ART sites in 18 counties across Kenya from May to June 2015. Thematic content analysis identified themes for three EWIs: on-time pill pick-up, retention in care, and virological suppression. Results Nine themes—six at the facility level and three at the patient level—emerged as major challenges to EWI monitoring. At the facility level, themes centered on system issues (e.g., slow return of viral load results), staff shortages and inadequate adherence counseling skills, lack of effective patient tracking and linkage systems, and lack of support for health personnel. At the patient level, themes focused on stigma, non-disclosure of HIV status to children who are age eligible, and little engagement of guardians in the children’s care. Practical solutions identified included the use of lay health workers (e.g., peer educators, community health workers) to implement a variety of care and treatment tasks, whole facility approaches to adherence counseling, adolescent peer support groups, and working with children directly as soon as they are age eligible. Discussion The monitoring of EWIs has not been routine in health facilities in Kenya due to several challenges. However, facilities have implemented novel strategies to address some of these barriers. Future work is needed to assess whether scale-up of some of these approaches can aid in the effective use of EWIs and improving HIV care outcomes among the pediatric population.
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Affiliation(s)
- Nanlesta A Pilgrim
- Population Council, 4301 Connecticut Avenue NW, Suite 280, Washington, DC, 20008, USA.
| | | | | | - Irene Mukui
- National AIDS & STI Control Programme, Nairobi, Kenya
| | - Samuel Kalibala
- Population Council, 4301 Connecticut Avenue NW, Suite 280, Washington, DC, 20008, USA
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15
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Wexler C, Cheng AL, Gautney B, Finocchario-Kessler S, Goggin K, Khamadi S. Evaluating turnaround times for early infant diagnosis samples in Kenya from 2011-2014: A retrospective analysis of HITSystem program data. PLoS One 2017; 12:e0181005. [PMID: 28796791 PMCID: PMC5552093 DOI: 10.1371/journal.pone.0181005] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Accepted: 06/23/2017] [Indexed: 01/08/2023] Open
Abstract
Long turnaround times (TAT) for the processing and posting of results of infant HIV DNA PCR samples can hinder the success of early infant diagnosis (EID) programs. The HITSystem is an eHealth intervention that alerts staff when services are overdue or results are delayed. We conducted a retrospective analysis of 3669 HIV-exposed infants enrolled in 15 Kenya hospital EID programs and three laboratories using the HITSystem from 2011–2014. We assessed mean and median TAT from when a sample was: 1) obtained to when it was shipped to the laboratory, 2) shipped to when it was received at the laboratory, 3) received to when a result was posted, and 4) the total time from obtaining the sample (step 1) to posting the result (step 3). TAT were compared by laboratory, clinic, year, and month of sample collection. 3625 infant samples had results posted by end of 2014. Mean TAT from sample collection to shipping was 5.2 days, from shipping to laboratory receipt was 2.0 days, and from laboratory receipt to result posting was 17.4 days. Altogether, it took an average of 24.7 days from sample collection until result posting. There was significant variation between laboratories, particularly in laboratory processing times (step 3). TAT showed a decreasing trend from 2011–2014, although TAT in December remained higher. Compared with other Kenyan studies, TAT in these HITSystem enrolled settings were shorter. Significant variation between laboratories, however, indicates the need to strengthen protocols and infrastructure to ensure that all laboratories can provide rapid, high-quality services.
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Affiliation(s)
- Catherine Wexler
- University of Kansas Medical Center, Department of Family Medicine, Kansas City, Kansas, United States of America
- * E-mail:
| | - An-Lin Cheng
- University of Missouri-Kansas City, School of Medicine, Kansas City, Missouri, United States of America
| | - Brad Gautney
- Global Health Innovations, Kansas City, Missouri, United States of America
| | - Sarah Finocchario-Kessler
- University of Kansas Medical Center, Department of Family Medicine, Kansas City, Kansas, United States of America
| | - Kathy Goggin
- Children’s Mercy Hospitals and Clinics, Health Services and Outcomes Research, Kansas City, Missouri, United States of America
- University of Missouri-Kansas City, School of Medicine, Kansas City, Missouri, United States of America
- University of Missouri-Kansas City, School of Pharmacy, Kansas City, Missouri, United States of America
| | | | - HITSystem Team
- Global Health Innovations, Kansas City, Missouri, United States of America
- Kenya Medical Research Institute, Nairobi, Kenya
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Goggin K, Wexler C, Nazir N, Staggs VS, Gautney B, Okoth V, Khamadi SA, Ruff A, Sweat M, Cheng AL, Finocchario-Kessler S. Predictors of Infant Age at Enrollment in Early Infant Diagnosis Services in Kenya. AIDS Behav 2016; 20:2141-50. [PMID: 27108002 PMCID: PMC4995224 DOI: 10.1007/s10461-016-1404-z] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Despite the importance of early detection to signal lifesaving treatment initiation for HIV+ infants, early infant diagnosis (EID) services have received considerably less attention than other aspects of prevention of mother to child transmission care. This study draws on baseline data from an on-going cluster randomized study of an intervention to improve EID services at six government hospitals across Kenya. Two logistic regressions examined potential predictors of “on time” (infant ≤6 weeks of age) vs. “late” (≥7 weeks) and “on time” versus “very late” (≥12 weeks) EID engagement among 756 mother-infant pairs. A quarter of the infants failed to get “on time” testing. Predictors of “on time” testing included being informed about EID by providers when pregnant, perceiving less HIV stigma, and mother’s level of education. Predictors of “very late” testing (≥12 weeks of age) included not being informed about EID by providers when pregnant and living farther from services. Findings highlight the importance of ensuring that health care providers actively and repeatedly inform HIV+ mothers of the availability of EID services, reduce stigma by frequently communicating judgment free support, and assisting mothers in early planning for accessing EID services. Extra care should be focused on engaging mothers with less formal education who are at increased risk for seeking “late” EID testing. This study offers clear targets for improving services so that all HIV-exposed infants can be properly engaged in EID services, thus increasing the potential for the best possible outcomes for this vulnerable population.
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Affiliation(s)
- Kathy Goggin
- Children's Mercy Hospitals and Clinics, Health Services and Outcomes Research, 2401 Gillham Road, Kansas City, MO, 64108, USA.
- University of Missouri-Kansas City, School of Medicine, Kansas City, MO, USA.
- University of Missouri-Kansas City, School of Pharmacy, Kansas City, MO, USA.
| | - Catherine Wexler
- University of Kansas Medical Center, Department of Family Medicine, Kansas City, KS, USA
| | - Niaman Nazir
- University of Kansas Medical Center, Department of Preventive Medicine, Kansas City, KS, USA
| | - Vincent S Staggs
- Children's Mercy Hospitals and Clinics, Health Services and Outcomes Research, 2401 Gillham Road, Kansas City, MO, 64108, USA
- University of Missouri-Kansas City, School of Medicine, Kansas City, MO, USA
| | | | | | | | - Andrea Ruff
- Johns Hopkins Bloomberg School of Public Health, Department of International Health, Baltimore, MD, USA
| | - Michael Sweat
- Medical University of South Carolina, Department of Psychiatry and Behavioral Sciences, Charleston, SC, USA
| | - An-Lin Cheng
- University of Missouri-Kansas City, School of Nursing and Health Studies, Kansas City, MO, USA
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Uptake of early infant diagnosis in Thailand's national program for preventing mother-to-child HIV transmission and linkage to care, 2008-2011. J Int AIDS Soc 2016; 19:20511. [PMID: 26968214 PMCID: PMC4788772 DOI: 10.7448/ias.19.1.20511] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Revised: 12/22/2015] [Accepted: 01/28/2016] [Indexed: 11/13/2022] Open
Abstract
Introduction Early infant diagnosis (EID) has been a component of Thailand's prevention of mother-to-child HIV transmission (PMTCT) programme since 2007. This study assessed the uptake, EID coverage, proportion of HIV-exposed infants receiving a definitive HIV diagnosis, mother-to-child transmission (MTCT) rates and linkage to HIV care and treatment. Methods Infant polymerase chain reaction (PCR) testing data from the National AIDS Program database were analyzed. EID coverage was calculated as the percentage of number of HIV-exposed infants receiving ≥1 HIV PCR test divided by the number of HIV-exposed infants estimated from HIV prevalence and live-birth registry data. Definitive HIV diagnosis was defined as having two concordant PCR results. MTCT rates were calculated based on infants tested with PCR and applied as a best-case scenario, and a sensitivity analysis was used to adjust these rates in average and worst scenarios. We defined linkage to HIV care as infants with at least one PCR-positive test who were registered with Thailand's National AIDS Program. Chi-squared tests for linear trend were used to analyze changes in programme coverage. Results For 2008 to 2011, the average EID coverage rate increased from 54 to 76% (p<0.001), with 65% coverage (13,761/21,099) overall. The number of hospitals submitting EID samples increased from 458 to 645, and the percentage of community hospitals submitting samples increased from 75 to 78% (p=0.044). A definitive HIV diagnosis was made for 10,854 (79%) infants during this period. The adjusted MTCT rates had significantly decreasing trends in all scenarios. Overall, an estimated 53% (429/804) of HIV-infected infants were identified through the EID programme, and 80% (341/429) of infants testing positive were linked to care. The overall rate of antiretroviral treatment (ART) initiation within one year of age was 37% (157/429), with an increasing trend from 28 to 52% (p<0.001). Conclusions EID coverage increased and MTCT rates decreased during 2008 to 2011; however, about half of HIV-infected infants still did not receive EID. Most HIV-infected infants were linked to care but less than half initiated ART within one year of age. Active follow-up of HIV-exposed infants to increase early detection of HIV infection and early initiation of ART should be more widely implemented.
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