A viable, cost-effective solution at scale has been developed and implemented for collecting electronic data during household visits in a resource-constrained setting.

Summary Background There is limited research characterizing the HIV care continuum with population-based data in sub-Saharan Africa. The objectives of this study were to: 1) describe engagement in care among all known HIV-positive adults in one sub-county of western Kenya; and 2) determine the time to and predictors of linkage and engagement among adults newly diagnosed via home-based counseling and testing (HBCT). Methods AMPATH (Academic Model Providing Access to Healthcare) has provided HIV care in western Kenya since 2001 and HBCT since 2007. Following a widespread HBCT program in Bunyala sub-county, electronic medical records (EMR) were reviewed to identify uptake of care among individuals with previously known (self-reported) infection and new (identified by HBCT) HIV diagnoses as of June 2014. Engagement in HIV care was defined as an initial encounter with an HIV care provider. Cox regression analysis was used to examine the predictors of engagement among those newly diagnosed. Findings Of the 3,482 infected adults identified, 61% had previously known infections, among whom 84% (n = 1778/2122) had ever had at least one clinical encounter within AMPATH. While 73% were registered in the EMR, only 15% (n = 209/1360) of the newly diagnosed had seen a clinician over a median of 3·4 years. The median time to engagement among the newly diagnosed was 60 days (interquartile range: 10–411 days). Interpretation Engagement in care was high among those who at the time of HBCT were already known HIV-positive, but few who were newly diagnosed in HBCT saw an HIV care provider. Funding This research was supported by the President’s Emergency Plan for AIDS Relief (PEPFAR) through USAID under the terms of Cooperative Agreement No. AID-623-A-12-0001. The HBCT program was supported by grants from Abbott Laboratories, the Purple ville Foundation, and the Global Business Coalition. Abbott Laboratories provided test kits and logistical support. Further support was provided by the National Institute of Mental Health (K01MH099966, PI: Genberg) and the Bill and Melinda Gates Foundation. The contents of this study are the sole responsibility of the authors and do not necessarily reflect the views of USAID, NIMH, BMGF, or the United States Government.

BackgroundThe burdens of hypertension and diabetes are increasing in low- and middle-income countries (LMICs). It is important to identify patients with these conditions early in the disease process. The goal of this study, therefore, is to compare community- versus home-based screening for hypertension and diabetes in Kenya.MethodsThis was a feasibility study conducted by the Academic Model Providing Access to Healthcare (AMPATH) program in Webuye, a town in western Kenya. Home-based (door-to-door) screening occurred in March 2010 and community-based screening in November 2011. HIV counselors were trained to screen for diabetes and hypertension in the home-based screening with local district hospital based staff conducting the community-based screening. Participants >18 years old qualified for screening in both groups. Counselors referred all participants with a systolic blood pressure (SBP) ≥160 mmHg and/or a random blood glucose ≥7 mmol/L (126 mg/dL) to a local clinic for follow-up. Differences in likelihood of screening positive between the two strategies were compared using Fischer’s Exact Test. Logistic regression models were used to identify factors associated with the likelihood of following-up after a positive screening.ResultsThere were 236 participants in home-based screening: 13 (6%) had a SBP ≥160 mmHg, and 54 (23%) had a random glucose ≥ 7 mmol/L. There were 346 participants in community-based screening: 35 (10%) had a SBP ≥160 mmHg, and 27 (8%) had a random glucose ≥ 7 mmol/L. Participants in community-based screening were twice as likely to screen positive for hypertension compared to home-based screening (OR=1.93, P=0.06). In contrast, participants were 3.5 times more likely to screen positive for a random blood glucose ≥7 mmol/L with home-based screening (OR=3.51, P<0.01). Rates for following-up at the clinic after a positive screen were low for both groups with 31% of patients with an elevated SBP returning for confirmation in both the community-based and home-based group (P=1.0). Follow-up after a random glucose was also low with 23% returning in the home-based group and 22% in the community-based group (P=1.0).ConclusionCommunity- or home-based screening for diabetes and hypertension in LMICs is feasible. Due to low rates of follow-up, screening efforts in rural settings should focus on linking cases to care.

HBCT is effective at getting HIV-infected persons enrolled in HIV care before they become ill.

BackgroundHIV linkage and retention rates in sub-Saharan Africa remain low. The objective of this study was to explore perceived health facility barriers to linkage and retention in an HIV care program in western Kenya.MethodsThis qualitative study was conducted July 2012-August 2013. A total of 150 participants including; 59 patients diagnosed with HIV, TB, or hypertension; 16 caregivers; 10 community leaders; and 65 healthcare workers, were purposively sampled from three Academic Model Providing Access to Healthcare (AMPATH) sites. We conducted 16 in-depth interviews and 17 focus group discussions (FGDs) in either, English, Swahili, Kalenjin, Teso, or Luo. All data were audio recorded, transcribed, translated to English, and a content analysis performed. Demographic data was only available for those who participated in the FGDs.ResultsThe mean age of participants in the FGDs was 36 years (SD = 9.24). The majority (87%) were married, (62.7%) had secondary education level and above, and (77.6%) had a source of income. Salient barriers identified reflected on patients’ satisfaction with HIV care. Barriers unique to linkage were reported as quality of post-test counseling and coordination between HIV testing and care. Those unique to retention were frequency of clinic appointments, different appointments for mother and child, lack of HIV care for institutionalized populations including students and prisoners, lack of food support, and inconsistent linkage data. Barriers common to both linkage and retention included access to health facilities, stigma associated with health facilities, service efficiency, poor provider-patient interactions, and lack of patient incentives.ConclusionOur findings revealed that there were similarities and differences between perceived barriers to linkage and retention. The cited barriers reflected on the need for a more patient-centered approach to HIV care. Addressing health facility barriers may ultimately be more efficient and effective than addressing patient related barriers.

BackgroundResults: There were 47,066 households approached in 294 villages: 97% of households allowed entry. Of the 138,026 individuals captured, 101,167 individuals were eligible for testing: 89% of adults and 58% of children consented to HIV testing. The prevalence of HIV in these communities was 3.0%: 2.7% in adults and 3.7% among children. Prevalence was highest in the 36-45 year age group and was almost always higher among women and girls. All persons testing HIV-positive were referred to Academic Model Providing Access to Healthcare (AMPATH) for further assessment and care; all consenting persons were counselled on HIV risk-lowering behaviours. Conclusion: Home-based HIV counselling and testing was feasible among this rural population in western Kenya, with a majority of the population accepting to get tested. These data suggest that scaling-up of HBCT is possible and may enable large numbers of individuals to know their HIV serostatus in sub-Saharan Africa. More research is needed to describe the cost-effectiveness and clinical impact of this approach.

Sociodemographic and socioeconomic factors were independently associated with HIV testing and prevalence among the age groups. Community-based treatment and prevention strategies will need to consider these factors.

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