Last data update: May 20, 2024. (Total: 46824 publications since 2009)
Records 1-18 (of 18 Records) |
Query Trace: Kwaro D[original query] |
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Prevalence and risk factors of sexually transmitted infections in the setting of a generalized HIV epidemic-a population-based study, western Kenya
Awuoche HC , Joseph RH , Magut F , Khagayi S , Odongo FS , Otieno M , Appolonia A , Odoyo-June E , Kwaro DO . Int J STD AIDS 2024 9564624241226487 BACKGROUND: Sexually transmitted infections (STIs) cause adverse health outcomes, including increasing HIV acquisition/transmission risk. We analyzed data from an HIV biomarker and behavioral survey to estimate STI prevalence, and explore associated factors in the setting of a generalized HIV epidemic in Siaya County, western Kenya. METHODS: Data were collected in March-September 2022 through face-to-face interviews using structured questionnaires; records from 9643 sexually active participants aged 13+ years were included in the analysis. We calculated weighted self-reported STI prevalence, by sex, age, and HIV status and explored associated factors using multivariable logistic regression. RESULTS: Median age was 37 years and 59.9% were female; HIV prevalence was 18.0%. Overall STI prevalence was 1.8%; 1.5-fold higher among males vs. females, and 2.6-fold higher among participants living with HIV vs. those without. HIV status and multiple sexual partners were independently associated with STI in both sexes. Mind-altering substance use and being circumcised were associated with STI among males. CONCLUSIONS: This study estimates STI prevalence in the setting of high HIV prevalence. Findings underscore the importance of: effective STI screening in HIV clinics and HIV testing and counseling in STI clinics; screening and counseling on substance use, and HIV pre-exposure prophylaxis; and intensive sexual health counseling in male circumcision programmes. |
HIV risk factors and risk perception among adolescent girls and young women: Results from a population-based survey in Western Kenya, 2018
Kamire V , Magut F , Khagayi S , Kambona C , Muttai H , Nganga L , Kwaro D , Joseph RH . J Acquir Immune Defic Syndr 2022 91 (1) 17-25 BACKGROUND: In sub-Saharan Africa, HIV prevalence in adolescent girls and young women (AGYW) is 2-fold to 3-fold higher than that in adolescent boys and young men. Understanding AGYW's perception of HIV risk is essential for HIV prevention efforts. METHODS: We analyzed data from a HIV biobehavioral survey conducted in western Kenya in 2018. Data from AGYW aged 15-24 years who had a documented HIV status were included. We calculated weighted prevalence and evaluated factors associated with outcomes of interest (HIV infection and high risk perception) using generalized linear models to calculate prevalence ratios. RESULTS: A total of 3828 AGYW were included; 63% were aged 15-19 years. HIV prevalence was 4.5% and 14.5% of sexually active AGYW had high risk perception. Over 70% of participants had accessed HIV testing and counseling in the past 12 months. Factors associated with both HIV infection and high risk perception included having an HIV-positive partner or partner with unknown status and having a sexually transmitted infection in the past 12 months. Having an older (by ≥10 years) partner was associated with HIV infection, but not high risk perception. Less than 30% of sexually active AGYW with 3 or more HIV risk factors had high perception of HIV risk. CONCLUSION: Gaps in perceived HIV risk persist among AGYW in Kenya. High access to HIV testing and prevention services in this population highlights platforms through which AGYW may be reached with improved risk counseling, and to increase uptake of HIV prevention strategies. |
A clinical decision support system is associated with reduced loss to follow-up among patients receiving HIV treatment in Kenya: a cluster randomized trial
Oluoch T , Cornet R , Muthusi J , Katana A , Kimanga D , Kwaro D , Okeyo N , Abu-Hanna A , de Keizer N . BMC Med Inform Decis Mak 2021 21 (1) 357 BACKGROUND: Loss to follow-up (LFTU) among HIV patients remains a major obstacle to achieving treatment goals with the risk of failure to achieve viral suppression and thereby increased HIV transmission. Although use of clinical decision support systems (CDSS) has been shown to improve adherence to HIV clinical guidance, to our knowledge, this is among the first studies conducted to show its effect on LTFU in low-resource settings. METHODS: We analyzed data from a cluster randomized controlled trial in adults and children (aged ≥ 18 months) who were receiving antiretroviral therapy at 20 HIV clinics in western Kenya between Sept 1, 2012 and Jan 31, 2014. Participating clinics were randomly assigned, via block randomization. Clinics in the control arm had electronic health records (EHR) only while the intervention arm had an EHR with CDSS. The study objectives were to assess the effects of a CDSS, implemented as alerts on an EHR system, on: (1) the proportion of patients that were LTFU, (2) LTFU patients traced and successfully linked back to treatment, and (3) time from enrollment on the study to documentation of LTFU. RESULTS: Among 5901 eligible patients receiving ART, 40.6% (n = 2396) were LTFU during the study period. CDSS was associated with lower LTFU among the patients (Adjusted Odds Ratio-aOR 0.70 (95% CI 0.65-0.77)). The proportions of patients linked back to treatment were 25.8% (95% CI 21.5-25.0) and 30.6% (95% CI 27.9-33.4)) in EHR only and EHR with CDSS sites respectively. CDSS was marginally associated with reduced time from enrollment on the study to first documentation of LTFU (adjusted Hazard Ratio-aHR 0.85 (95% CI 0.78-0.92)). CONCLUSION: A CDSS can potentially improve quality of care through reduction and early detection of defaulting and LTFU among HIV patients and their re-engagement in care in a resource-limited country. Future research is needed on how CDSS can best be combined with other interventions to reduce LTFU. Trial registration NCT01634802. Registered at www.clinicaltrials.gov on 12-Jul-2012. Registered prospectively. |
Menstrual cups and cash transfer to reduce sexual and reproductive harm and school dropout in adolescent schoolgirls: study protocol of a cluster-randomised controlled trial in western Kenya
Zulaika G , Kwaro D , Nyothach E , Wang D , Zielinski-Gutierrez E , Mason L , Eleveld A , Chen T , Kerubo E , van Eijk A , Pace C , Obor D , Juma J , Oyaro B , Niessen L , Bigogo G , Ngere I , Henry C , Majiwa M , Onyango CO , Ter Kuile FO , Phillips-Howard PA . BMC Public Health 2019 19 (1) 1317 BACKGROUND: Adolescent girls in sub-Saharan Africa are disproportionally vulnerable to sexual and reproductive health (SRH) harms. In western Kenya, where unprotected transactional sex is common, young females face higher rates of school dropout, often due to pregnancy, and sexually transmitted infections (STIs), including HIV. Staying in school has shown to protect girls against early marriage, teen pregnancy, and HIV infection. This study evaluates the impact of menstrual cups and cash transfer interventions on a composite of deleterious outcomes (HIV, HSV-2, and school dropout) when given to secondary schoolgirls in western Kenya, with the aim to inform evidence-based policy to improve girls' health, school equity, and life-chances. METHODS: Single site, 4-arm, cluster randomised controlled superiority trial. Secondary schools are the unit of randomisation, with schoolgirls as the unit of measurement. Schools will be randomised into one of four intervention arms using a 1:1:1:1 ratio and block randomisation: (1) menstrual cup arm; (2) cash transfer arm, (3) cups and cash combined intervention arm, or (4) control arm. National and county agreement, and school level consent will be obtained prior to recruitment of schools, with parent consent and girls' assent obtained for participant enrolment. Participants will be trained on safe use of interventions, with all arms receiving puberty and hygiene education. Annually, the state of latrines, water availability, water treatment, handwashing units and soap in schools will be measured. The primary endpoint is a composite of incident HIV, HSV-2, and all-cause school dropout, after 3 years follow-up. School dropout will be monitored each term via school registers and confirmed through home visits. HIV and HSV-2 incident infections and risk factors will be measured at baseline, mid-line and end-line. Intention to treat analysis will be conducted among all enrolled participants. Focus group discussions will provide contextual information on uptake of interventions. Monitoring for safety will occur throughout. DISCUSSION: If proved safe and effective, the interventions offer a potential contribution toward girls' schooling, health, and equity in low- and middle-income countries. TRIAL REGISTRATION: ClinicalTrials.gov NCT03051789 , 15th February 2017. |
Decreased HIV-associated mortality rates during scale-up of antiretroviral therapy, 2011-2016: a population-based cohort study
Otieno G , Whiteside YO , Achia T , Kwaro D , Zielinski-Gutierrez E , Ojoo S , Sewe M , Musingila P , Akelo V , Obor D , Nyaguara A , de Cock KM , Borgdorff MW . AIDS 2019 33 (15) 2423-2430 OBJECTIVE: HIV-associated mortality rates in Africa decreased by 10%-20% annually in 2003-2011, after the introduction of antiretroviral therapy (ART). We sought to document HIV-associated mortality rates in the general population in Kenya after 2011 in an era of expanded access to ART. DESIGN: We obtained data on mortality rates and migration from a health and demographic surveillance system (HDSS) in Gem, western Kenya, and data for HDSS residents aged 15-64 years from home-based HIV-counseling and testing (HBCT) rounds in 2011, 2012, 2013, and 2016. METHODS: Mortality trends were determined among a closed cohort of residents who participated in at least the 2011 round of HBCT. RESULTS: Of 32,467 eligible HDSS residents, 22,688 (70%) participated in the 2011 round and comprised the study cohort. All-cause mortality rates declined from 10.0 (95% confidence interval [CI] 8.4-11.7) per 1000 in 2011 to 7.4 (95% CI 5.7-9.0) in 2016, while the mortality rate was stable among HIV-uninfected residents, at 5.7 per 1000 person-years. Among HIV-infected residents, mortality rates declined from 30.5 per 1000 in 2011 to 15.9 per 1000 in 2016 (average decline, 6% per year). The HIV-infected group receiving ART had higher mortality rates than the HIV-uninfected group (adjusted rate ratio (aRR), 2.8; 95% CI 2.2-3.4), as did the HIV-infected group who did not receive ART (aRR, 5.3; 95% CI 4.5-6.2). CONCLUSIONS: Mortality rates among HIV-infected individuals declined substantially during ART expansion between 2011 and 2016, though less than during early ART introduction. Mortality trends among HIV-infected populations are critical to understanding epidemic dynamics. |
HIV incidence in western Kenya during scale-up of antiretroviral therapy and voluntary medical male circumcision: a population-based cohort analysis
Borgdorff MW , Kwaro D , Obor D , Otieno G , Kamire V , Odongo F , Owuor P , Muthusi J , Mills LA , Joseph R , Schmitz ME , Young PW , Zielinski-Gutierrez E , De Cock KM . Lancet HIV 2018 5 (5) e241-e249 BACKGROUND: In Kenya, coverage of antiretroviral therapy (ART) among people with HIV infection has increased from 7% in 2006, to 57% in 2016; and, in western Kenya, coverage of voluntary medical male circumcision (VMMC) increased from 45% in 2008, to 72% in 2014. We investigated trends in HIV prevalence and incidence in a high burden area in western Kenya in 2011-16. METHODS: In 2011, 2012, and 2016, population-based surveys were done via a health and demographic surveillance system and home-based counselling and testing in Gem, Siaya County, Kenya, including 28 688, 17 021, and 16 772 individuals aged 15-64 years. Data on demographic variables, self-reported HIV status, and risk factors were collected. Rapid HIV testing was offered to survey participants. Participants were tracked between surveys by use of health and demographic surveillance system identification numbers. HIV prevalence was calculated as a proportion, and HIV incidence was expressed as number of new infections per 1000 person-years of follow-up. FINDINGS: HIV prevalence was stable in participants aged 15-64 years: 15% (4300/28 532) in 2011, 12% (2051/16 875) in 2012, and 15% (2312/15 626) in 2016. Crude prevalences in participants aged 15-34 years were 11% (1893/17 197) in 2011, 10% (1015/10 118) in 2012, and 9% (848/9125) in 2016; adjusted for age and sex these prevalences were 11%, 9%, and 8%. 12 606 (41%) of the 30 520 non-HIV-infected individuals enrolled were seen again in at least one more survey round, and were included in the analysis of HIV incidence. HIV incidence was 11.1 (95% CI 9.1-13.1) per 1000 person-years from 2011 to 2012, and 5.7 (4.6-6.9) per 1000 person-years from 2012 to 2016. INTERPRETATION: With increasing coverage of ART and VMMC, HIV incidence declined substantially in Siaya County between 2011 and 2016. VMMC, but not ART, was suggested to have a direct protective effect, presumably because ART tended to be given to individuals with advanced HIV infection. HIV incidence is still high and not close to the elimination target of one per 1000 person-years. The effect of further scale-up of ART and VMMC needs to be monitored. FUNDING: Data were collected under Cooperative Agreements with the US Centers for Disease Control and Prevention, with funding from the President's Emergency Fund for AIDS Relief. |
From policy to practice: exploring the implementation of antiretroviral therapy access and retention policies between 2013 and 2016 in six sub-Saharan African countries
Ambia J , Renju J , Wringe A , Todd J , Geubbels E , Nakiyingi-Miiro J , Urassa M , Lutalo T , Crampin AC , Kwaro D , Kyobutungi C , Chimbindi N , Gomez-Olive FX , Tlhajoane M , Njamwea B , Zaba B , Mee P . BMC Health Serv Res 2017 17 (1) 758 BACKGROUND: Understanding the implementation of 2013 World Health Organization (WHO) consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection at the facility level provides important lessons for the roll-out of future HIV policies. METHODS: A national policy review was conducted in six sub-Saharan African countries to map the inclusion of the 2013 WHO HIV treatment recommendations. Twenty indicators of policy adoption were selected to measure ART access (n = 12) and retention (n = 8). Two sequential cross-sectional surveys were conducted in facilities between 2013/2015 (round 1) and 2015/2016 (round 2) from ten health and demographic surveillance sites in Kenya, Malawi, South Africa, Tanzania, Uganda and Zimbabwe. Using standardised questionnaires, facility managers were interviewed. Descriptive analyses were used to assess the change in the proportion of facilities that implemented these policy indicators between rounds. RESULTS: Although, expansion of ART access was explicitly stated in all countries' policies, most lacked policies that enhanced retention. Overall, 145 facilities were included in both rounds. The proportion of facilities that initiated ART at CD4 counts of 500 or less cells/muL increased between round 1 and 2 from 12 to 68%, and facilities initiating patients on 2013 WHO recommended ART regimen increased from 42 to 87%. There were no changes in the proportion of facilities reporting stock-outs of first-line ART in the past year (18 to 11%) nor in the provision of three-month supply of ART (43 to 38%). None of the facilities provided community-based ART delivery. CONCLUSION: The increase in ART initiation CD4 threshold in most countries, and substantial improvements made in the provision of WHO recommended first-line ART regimens demonstrates that rapid adoption of WHO recommendations is possible. However, improved logistics and resources and/or changes in policy are required to further minimise ART stock-outs and allow lay cadres to dispense ART in the community. Increased efforts are needed to offer longer durations between clinic visits, a strategy purported to improve retention. These changes will be important as countries move to implement the revised 2015 WHO guidelines to initiate all HIV positive people onto ART regardless of their immune status. |
Emergence of untreatable, multidrug-resistant HIV-1 in patients failing second-line therapy in Kenya
Inzaule SC , Hamers RL , Mukui I , Were K , Owiti P , Kwaro D , de Wit TF , Zeh C . AIDS 2017 31 (10) 1495-1498 We performed a countrywide assessment of HIV drug resistance among 123 patients with virological failure on second-line antiretroviral therapy (ART) in Kenya. The percentage of patients harboring intermediate-to-high-level resistance was 27% for lopinavir-ritonavir, 24% for atazanavir-ritonavir and 7% for darunavir-ritonavir, and 25% had complete loss of activity to all available first- and second-line drugs. Overall, one in four patients failing second-line ART have completely exhausted available antiretrovirals in Kenya, highlighting the need for increased access to third-line drugs. |
Data resource profile: Network for analysing longitudinal population-based HIV/AIDS data on Africa (ALPHA Network)
Reniers G , Wamukoya M , Urassa M , Nyaguara A , Nakiyingi-Miiro J , Lutalo T , Hosegood V , Gregson S , Gomez-Olive X , Geubbels E , Crampin AC , Wringe A , Waswa L , Tollman S , Todd J , Slaymaker E , Serwadda D , Price A , Oti S , Nyirenda MJ , Nabukalu D , Nyamukapa C , Nalugoda F , Mugurungi O , Mtenga B , Mills L , Michael D , McLean E , McGrath N , Martin E , Marston M , Maquins S , Levira F , Kyobutungi C , Kwaro D , Kasamba I , Kanjala C , Kahn K , Kabudula C , Herbst K , Gareta D , Eaton JW , Clark SJ , Church K , Chihana M , Calvert C , Beguy D , Asiki G , Amri S , Abdul R , Zaba B . Int J Epidemiol 2016 45 (1) 83-93 The Network for Analysing Longitudinal Population-based HIV/AIDS data on Africa (ALPHA Network) was established in 2005 and aims to: (i) broaden the evidence base on HIV epidemiology for informing policy; (ii) strengthen analytical capacity for HIV research; and (iii) foster collaboration between study sites. All of the study sites participating in the ALPHA Network are independently managed and have their own scientific agendas and tailored research methodologies, but share a common interest in HIV epidemiology and its interactions with the socio-demographic characteristics of the populations they cover. |
Effect of a clinical decision support system on early action on immunological treatment failure in patients with HIV in Kenya: A cluster randomised controlled trial
Oluoch T , Katana A , Kwaro D , Santas X , Langat P , Mwalili S , Muthusi K , Okeyo N , Ojwang JK , Cornet R , Abu-Hanna A , de Keizer N . Lancet HIV 2015 3018 (15) 00242-8 BACKGROUND: A clinical decision support system (CDSS) is a computer program that applies a set of rules to data stored in electronic health records to offer actionable recommendations. We aimed to establish whether a CDSS that supports detection of immunological treatment failure among patients with HIV taking antiretroviral therapy (ART) would improve appropriate and timely action. METHODS: We did this prospective, cluster randomised controlled trial in adults and children (aged ≥18 months) who were eligible for, and receiving, ART at HIV clinics in Siaya County, western Kenya. Health facilities were randomly assigned (1:1), via block randomisation (block size of two) with a computer-generated random number sequence, to use electronic health records either alone (control) or with CDSS (intervention). Facilities were matched by type and by number of patients enrolled in HIV care. The primary outcome measure was the difference between groups in the proportion of patients who experienced immunological treatment failure and had a documented clinical action. We used generalised linear mixed models with random effects to analyse clustered data. This trial is registered with ClinicalTrials.gov, number NCT01634802. FINDINGS: Between Sept 1, 2012, and Jan 31, 2014, 13 clinics, comprising 41 062 patients, were randomly assigned to the control group (n=6) or the intervention group (n=7). Data collection at each site took 12 months. Among patients eligible for ART, 10 358 (99%) of 10 478 patients were receiving ART at control sites and 10 991 (99%) of 11 028 patients were receiving ART at intervention sites. Of these patients, 1125 (11%) in the control group and 1342 (12%) in the intervention group had immunological treatment failure, of whom 332 (30%) and 727 (54%), respectively, received appropriate action. The likelihood of clinicians taking appropriate action on treatment failure was higher with CDSS alerts than with no decision support system (adjusted odds ratio 3·18, 95% CI 1·02-9·87). INTERPRETATION: CDSS significantly improved the likelihood of appropriate and timely action on immunological treatment failure. We expect our findings will be generalisable to virological monitoring of patients with HIV receiving ART once countries implement the 2015 WHO recommendation to scale up viral load monitoring. |
Menstrual needs and associations with sexual and reproductive risks in rural Kenyan females: a cross-sectional behavioral survey linked with HIV prevalence
Phillips-Howard PA , Otieno G , Burmen B , Otieno F , Odongo F , Odour C , Nyothach E , Amek N , Zielinski-Gutierrez E , Odhiambo F , Zeh C , Kwaro D , Mills LA , Laserson KF . J Womens Health (Larchmt) 2015 24 (10) 801-11 BACKGROUND: Females in low and middle income countries (LMICs) have difficulty coping with menstrual needs, but few studies have examined the social or health implications of these needs. METHODS: Responses from 3418 menstruating females aged 13-29 years were extracted from an HIV and behavioral risks cross-sectional survey conducted in rural western Kenya. We examined sanitary products used, provision of products from sexual partners or from transactional sex, and demographic and sexual exposures. RESULTS: Overall, 75% of females reported using commercial pads and 25% used traditional materials such as cloth or items like paper or tissue, with 10% of girls <15 years old depending on makeshift items. Two-thirds of females with no education relied on traditional items. Having attended secondary school increased the odds of using commercial pads among married (adjusted odds ratios [AOR] 4.8, 95% confidence interval [CI] 3.25-7.12) and single females (AOR 2.17, 95% CI 1.04-4.55). Married females had lower odds of pad use if they reported early (<12 years of age) compared with later (≥18 years) sexual debut (64% vs. 78%, AOR 0.45, 95% CI 0.21-0.97). Two-thirds of pad users received them from sexual partners. Receipt was lower among married females if partners were violent (AOR 0.67, 95% CI 0.53-0.85). Receipt among single females was higher if they had two or more sexual partners in the past year (AOR 2.11, 95% CI 1.04-4.29). Prevalence of engaging in sex for money to buy pads was low (1.3%); however, 10% of 15-year-olds reported this, with girls ≤15 having significantly higher odds compared with females over 15 (AOR 2.84, 95% CI 0.89-9.11). The odds of having transactional sex for pads was higher among females having two or more partners in the past 12 months (AOR 4.86, 95% CI 2.06-11.43). CONCLUSIONS: Menstrual needs of impoverished females in rural LMICs settings likely leads to increased physical and sexual harms. Studies are required to strengthen knowledge and to evaluate interventions to reduce these harms. |
A structured approach to recording AIDS-defining illnesses in Kenya: a SNOMED CT based solution
Oluoch T , de Keizer N , Langat P , Alaska I , Ochieng K , Okeyo N , Kwaro D , Cornet R . J Biomed Inform 2015 56 387-94 INTRODUCTION: Several studies conducted in sub-Saharan Africa (SSA) have shown that routine clinical data in HIV clinics often have errors. Lack of structured and coded documentation of diagnosis of AIDS defining illnesses (ADIs) can compromise data quality and decisions made on clinical care. METHODS: We used a structured framework to derive a reference set of concepts and terms used to describe ADIs. The four sources used were: (i) CDC/Accenture list of opportunistic infections, (ii) SNOMED Clinical Terms (SNOMED CT), (iii) Focus Group Discussion (FGD) among clinicians and nurses attending to patients at a referral provincial hospital in western Kenya, and (iv) chart abstraction from the Maternal Child Health (MCH) and HIV clinics at the same hospital. Using the January 2014 release of SNOMED CT, concepts were retrieved that matched terms abstracted from approach iii & iv, and the content coverage assessed. Post-coordination matching was applied when needed. RESULTS: The final reference set had 1054 unique ADI concepts which were described by 1860 unique terms. Content coverage of SNOMED CT was high (99.9% with pre-coordinated concepts; 100% with post-coordination). The resulting reference set for ADIs was implemented as the interface terminology on OpenMRS data entry forms. CONCLUSION: Different sources demonstrate complementarity in the collection of concepts and terms for an interface terminology. SNOMED CT provides a high coverage in the domain of ADIs. Further work is needed to evaluate the effect of the interface terminology on data quality and quality of care. |
Developing a national-level concept dictionary for EHR implementations in Kenya
Keny A , Wanyee S , Kwaro D , Mulwa E , Were MC . Stud Health Technol Inform 2015 216 780-4 The increasing adoption of Electronic Health Records (EHR) by developing countries comes with the need to develop common terminology standards to assure semantic interoperability. In Kenya, where the Ministry of Health has rolled out an EHR at 646 sites, several challenges have emerged including variable dictionaries across implementations, inability to easily share data across systems, lack of expertise in dictionary management, lack of central coordination and custody of a terminology service, inadequately defined policies and processes, insufficient infrastructure, among others. A Concept Working Group was constituted to address these challenges. The country settled on a common Kenya data dictionary, initially derived as a subset of the Columbia International eHealth Laboratory (CIEL) / Millennium Villages Project (MVP) dictionary. The initial dictionary scope largely focuses on clinical needs. Processes and policies around dictionary management are being guided by the framework developed by Bakhshi-Raiez et al. Technical and infrastructure-based approaches are also underway to streamline workflow for dictionary management and distribution across implementations. Kenya's approach on comprehensive common dictionary can serve as a model for other countries in similar settings. |
Better adherence to pre-antiretroviral therapy guidelines after implementing an electronic medical record system in rural Kenyan HIV clinics: a multicenter pre-post study
Oluoch T , Kwaro D , Ssempijja V , Katana A , Langat P , Okeyo N , Abu-Hanna A , de Keizer N . Int J Infect Dis 2014 33 109-13 INTRODUCTION: The monitoring of pre-antiretroviral therapy (pre-ART) is a key indicator of HIV quality of care. This study investigated the association of an electronic medical record system (EMR) with adherence to pre-ART guidelines in rural HIV clinics in Kenya. METHODS: A retrospective study was carried out to assess the quality of pre-ART care using three indicators: (1) the performance of a baseline CD4 test, (2) time from enrollment in care to first CD4 test, and (3) time from baseline CD4 to second CD4 test. A comparison of these indicators was made pre and post the introduction of an EMR system in 17 rural HIV clinics. RESULTS: A total of 18523 patients were receiving pre-ART care, of whom 38.8% in the paper group had had at least one CD4 test compared to 53.4% in the EMR group (p<0.001). The adjusted odds of performing a CD4 test in clinics using an EMR was 1.59 (95% confidence interval 1.49-1.69). The median time from enrolment into HIV care to first CD4 test was 1.40 months (interquartile range (IQR) 0.47-4.87) for paper vs. 0.93 months (IQR 0.43-3.37) for EMR. The median time from baseline to first CD4 follow-up was 7.5 months (IQR 5.97-10.73) for paper and 6.53 months (IQR 5.57-7.87) for EMR. CONCLUSION: The use of the EMR system was associated with better compliance to HIV guidelines for pre-ART care. EMRs have a potential positive impact on quality of care for HIV patients in resource-constrained settings. |
Electronic medical record systems are associated with appropriate placement of HIV patients on antiretroviral therapy in rural health facilities in Kenya: a retrospective pre-post study
Oluoch T , Katana A , Ssempijja V , Kwaro D , Langat P , Kimanga D , Okeyo N , Abu-Hanna A , de Keizer N . J Am Med Inform Assoc 2014 21 (6) 1009-14 BACKGROUND AND OBJECTIVE: There is little evidence that electronic medical record (EMR) use is associated with better compliance with clinical guidelines on initiation of antiretroviral therapy (ART) among ART-eligible HIV patients. We assessed the effect of transitioning from paper-based to an EMR-based system on appropriate placement on ART among eligible patients. METHODS: We conducted a retrospective, pre-post EMR study among patients enrolled in HIV care and eligible for ART at 17 rural Kenyan clinics and compared the: (1) proportion of patients eligible for ART based on CD4 count or WHO staging who initiate therapy; (2) time from eligibility for ART to ART initiation; (3) time from ART initiation to first CD4 test. RESULTS: 7298 patients were eligible for ART; 54.8% (n=3998) were enrolled in HIV care using a paper-based system while 45.2% (n=3300) were enrolled after the implementation of the EMR. EMR was independently associated with a 22% increase in the odds of initiating ART among eligible patients (adjusted OR (aOR) 1.22, 95% CI 1.12 to 1.33). The proportion of ART-eligible patients not receiving ART was 20.3% and 15.1% for paper and EMR, respectively (chi2=33.5, p<0.01). Median time from ART eligibility to ART initiation was 29.1 days (IQR: 14.1-62.1) for paper compared to 27 days (IQR: 12.9-50.1) for EMR. CONCLUSIONS: EMRs can improve quality of HIV care through appropriate placement of ART-eligible patients on treatment in resource limited settings. However, other non-EMR factors influence timely initiation of ART. |
Incidence and predictors of first line antiretroviral regimen modification in western Kenya
Inzaule S , Otieno J , Kalyango J , Nafisa L , Kabugo C , Nalusiba J , Kwaro D , Zeh C , Karamagi C . PLoS One 2014 9 (4) e93106 BACKGROUND: Limited antiretroviral treatment regimens in resource-limited settings require long-term sustainability of patients on the few available options. We evaluated the incidence and predictors of combined antiretroviral treatment (cART) modifications, in an outpatient cohort of 955 patients who initiated cART between January 2009 and January 2011 in western Kenya. METHODS: cART modification was defined as either first time single drug substitution or switch. Incidence rates were determined by Poisson regression and risk factor analysis assessed using multivariate Cox regression modeling. RESULTS: Over a median follow-up period of 10.7 months, 178 (18.7%) patients modified regimens (incidence rate (IR); 18.6 per 100 person years [95% CI: 16.2-21.8]). Toxicity was the most common cited reason (66.3%). In adjusted multivariate Cox piecewise regression model, WHO disease stage III/IV (aHR; 1.82, 95%CI: 1.25-2.66), stavudine (d4T) use (aHR; 2.21 95%CI: 1.49-3.30) and increase in age (aHR; 1.02, 95%CI: 1.0-1.04) were associated with increased risk of treatment modification within the first year post-cART. Zidovudine (AZT) and tenofovir (TDF) use had a reduced risk for modification (aHR; 0.60 95%CI: 0.38-0.96 and aHR; 0.51 95%CI: 0.29-0.91 respectively). Beyond one year of treatment, d4T use (aHR; 2.75, 95% CI: 1.25-6.05), baseline CD4 counts ≤350 cells/mm3 (aHR; 2.45, 95%CI: 1.14-5.26), increase in age (aHR; 1.05 95%CI: 1.02-1.07) and high baseline weight >60kg aHR; 2.69 95% CI: 1.58-4.59) were associated with risk of cART modification. CONCLUSIONS: Early treatment initiation at higher CD4 counts and avoiding d4T use may reduce treatment modification and subsequently improve sustainability of patients on the available limited options. |
Inconsistencies between recorded opportunistic infections and WHO HIV staging in western Kenya
Oluoch T , de Keizer N , Kwaro D , Wattoyi I , Okeyo N , Cornet R . Stud Health Technol Inform 2013 192 1139 Opportunistic infections (OIs) are the main cause of morbidity and mortality among patients with HIV in developing countries. It is therefore critical that accurate diagnoses are made and that they are correctly recorded and managed. We reviewed 200 randomly selected records of clinical encounters with HIV infected pregnant women attending the ante-natal care (ANC) clinic in July 2012 at the Jaramogi Oginga Odinga Teaching and Referral Hospital in Kenya. None of the clients in WHO stage 4 and 2.8% of those in WHO stage 3 had a new OI diagnosis recorded during the clinical encounter. This data suggests current under-recording of OIs and the inconsistency between WHO staging and OI diagnosis. Structured methods such as SNOMED CT have the potential to improve complete and accurate recording of OIs which, in turn, enable automatedand accurate WHO staging. |
The effect of electronic medical record-based clinical decision support on HIV care in resource-constrained settings: A systematic review
Oluoch T , Santas X , Kwaro D , Were M , Biondich P , Bailey C , Abu-Hanna A , de Keizer N . Int J Med Inform 2012 81 (10) e83-92 BACKGROUND: It is estimated that one million people infected with HIV initiate anti-retroviral therapy (ART) in resource-constrained countries annually. This occurs against a background of overburdened health workers with limited skills to handle rapidly changing treatment standards and guidelines hence compromising quality of care. Electronic medical record (EMR)-based clinical decision support systems (CDSS) are considered a solution to improve quality of care. Little evidence, however, exists on the effectiveness of EMR-based CDSS on quality of HIV care and treatment in resource-constrained settings. OBJECTIVE: The aim of this systematic review was to identify original studies on EMR-based CDSS describing process and outcome measures as well as reported barriers to their implementation in resource-constrained settings. We characterized the studies by guideline adherence, data and process, and barriers to CDSS implementation. METHODS: Two reviewers independently assessed original articles from a search of the MEDLINE, EMBASE, CINAHL and Global Health Library databases until January 2012. The included articles were those that evaluated or described the implementation of EMR-based CDSS that were used in HIV care in low-income countries. RESULTS: A total of 12 studies met the inclusion criteria, 10 of which were conducted in sub-Saharan Africa and 2 in the Caribbean. None of the papers described a strong (randomized controlled) evaluation design. Guideline adherence: One study showed that ordering rates for CD4 tests were significantly higher when reminders were used. Data and process: Studies reported reduction in data errors, reduction in missed appointments, reduction in missed CD4 results and reduction in patient waiting time. Two studies showed a significant increase in time spent by clinicians on direct patient care. Barriers to CDSS implementation: Technical infrastructure problems such as unreliable electric power and erratic Internet connectivity, clinicians' limited computer skills and failure by providers to comply with the reminders are key impediments to the implementation and effective use of CDSS. CONCLUSION: The limited number of evaluation studies, the basic and heterogeneous study designs, and varied outcome measures make it difficult to meaningfully conclude on the effectiveness of CDSS on quality of HIV care and treatment in resource-limited settings. High quality evaluation studies are needed. Factors specific to implementation of EMR-based CDSS in resource-limited setting should be addressed before such countries can demonstrate its full benefits. More work needs to be done to overcome the barriers to EMR and CDSS implementation in developing countries such as technical infrastructure and care providers' computer illiteracy. However, simultaneously evaluating and describing CDSS implementation strategies that work can further guide wise investments in their wider rollout. |
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