A comparative study of policy and practice factors influencing progression through the HIV care continuum in Kisumu and Nairobi in Kenya Fredrick Odhiambo Otieno Co-authors: C Cawley, E McRobie, D Kwaro, M Njage, J Todd, K Church, P Mee, B Zaba, S Oti, B Njamwea, A Nyaguara, A Wringe Barriers must fall 16:30 – 18:00, 21 July 2016 AIDS Conference, Durban Good afternoon, and thank you for the opportunity to present today the findings of a comparative study of policy and practice factors influencing progressions through the HIV care continuum in Kisumu and Nairobi in Kenya.

Background Diverse policies on HIV testing, PMTCT and ART across Africa [1] Little evidence of whether policies are implemented in health facilities Identifying policy implementation gaps essential for improving programmes and meeting 90:90:90 targets The ALPHA Network is a collaboration of 10 African Health and Demographic Surveillance sites (HDSS) ALPHA is investigating how HIV mortality may be influenced by HIV policies and their implementation. [1] Church et al. Bull WHO 2015 There are diverse national policies on HIV testing and counselling, prevention of mother-to-child transmission and antiretroviral therapy in African countries with generalised epidemics. However, there is little evidence as to whether these policies are implemented in practice in health facilities and whether the degree of implementation varies in different settings within the same country. Understanding which policies are actually applied in practice in health facilities can help to improve HIV programmes, and enable countries to better meet the 909090 targets. The network for Analysing Longitudinal Population data on HIV/AIDS (ALPHA) is a collaboration between 10 African Health and Demographic Surveillance sites (HDSS) in Southern and Eastern African countries with generalised epidemics. The ALPHA network is currently undertaking a study to investigate the timing of HIV deaths in relation to use of HIV services: in other words, to describe and compare the distribution of deaths across the HIV care cascade in each site. We do this using community cohort data with self-reported HIV service use or linked to HIV clinic records. To better understand the context within which these deaths occur, we have also been investigating health policy and service delivery factors that may influence HIV mortality across the HIV care and treatment cascade in each of the ALPHA partner sites

Aim and Setting Aim: To describe national HIV care and treatment policies, and assess their implementation in health facilities serving the HDSS populations in Kisumu and Nairobi Kisumu: ~ 132,000 residents in HDSS 95% Luo tribe Subsistence farming and fishing HIV prevalence ~ 15.1% (2012) In this presentation, we will consider the case of Kenya where there are 2 health and demographic surveillance sites participating in the ALPHA Network in Kisumu and Kenya. The overall aim is to describe national HIV care and treatment policies and assess their implementation in health facilities serving the HDSS population Kisumu is a predominantly rural area with a population of around 132000 in the surveillance area. Around 95% are from the Luo tribe and the main economic activities revolve around subsistence farming and fishing. HIV prevalence is just over 15%. In Nairobi, there are approximately 120,000 residents in the study area living in two informal settlements. HIV prevalence in this setting is much lower at just under 5%. Nairobi: ~ 120,000 residents in HDSS Two informal settlements (slums) HIV prevalence ~ 4,9% (2012) Figure: Location of 2 HDSS sites, Kisumu and Nairobi,

Conceptual framework We developed a conceptual framework that summarises the key HIV policy and programmatic factors that may influence HIV-related adult mortality across the continuum of care. These factors were derived from a review of the literature, a review of WHO policies and guidelines, and an expert review of indicators by 28 HIV researchers and clinicians Across the three points of attrition along the cascade - i.e. diagnosis, HIV care and retention – we found that the factors fell into the following five areas: (i) service access and coverage; (ii) quality of care; (iii) coordination of care and patient tracking; (iv) medical management; (v) support to PLHIV.

Methods Reviewed 20 national HIV policy documents covering HCT, PMTCT and ART published Jan 2003 - June 2013 Applied a policy extraction tool with pre-defined policy indicators to each document to capture key policy content and record whether policies were explicit, implicit or absent. Administered questionnaires on HCT, PMTCT and ART to in-charge staff at HIV clinics serving the HDSS populations in 2013. Measured the proportion of facilities implementing each policy Mortality rates among PLHIV in Kisumu were classified by last HIV clinic attended, by linking HIV clinic records with HDSS data In order to describe the HIV policies influencing HIV testing, care and treatment in the Kenya context, we then: Reviewed 20 national HIV policy documents covering HCT, PMTCT and ART published Jan 2003 - June 2013 We then applied a policy extraction tool with pre-defined policy indicators to each document to capture key policy content and record whether policies were explicit, implicit or absent. Having reviewed national level HIV policies, the next step was to measure the extent to which these policies were implemented in practice in the health facilities in the HDSS areas., To achieve this, we administered questionnaires on HCT, PMTCT and ART to in-charge staff at HIV clinics serving the HDSS populations in 2013. We measured the proportion of facilities implementing each policy. Finally, in Kisumu, where we had data on the last clinic that people living with HIV had used prior to their death linked to the HDSS data, we measured mortality rates among people living with HIV, and classified them by last HIV clinic attended

Results: Facilities surveyed 100% LARGE FACILITIES District referral hospital 80% Small hospital Large clinic Percentage of facilities 60% Small clinic SMALLER FACILITIES 40% Moving onto the results of the study… This slides shows the health facilities that we surveyed in each HDSS. In Nairobi, there were 10 main health facilities with HIV services serving the surveillance population. 4/10 were clinics while the remaining 6/10 were smaller or larger hospitals In Kisumu, there were 34 facilities that were surveyed, with 88% being either dispensaries or small health centres. 20% 0% Nairobi (n=10) Kisumu (n=34) HDSS SITE

Health facility characteristics   Nairobi Kisumu Total number of clinics (n(%)) 10 (100) 34 (100) HIV testing 100 PMTCT HIV care and treatment 80 94 HR indicators (median (range)) Clinicians* 2.5 (0-8) 1 (0 - 34.5) Nurses/midwives 6.5 (0 -18) 2 (0-62) HIV testing clients/week 78 (11-1237) 39 (0-206) Weekly HTC clients/staff+ 1.3 (0.8-42) 3.7 (0-41.2) No. ART clients/week 50 (35-141) 37 (0-154) *Doctor, clinical officer, assistant medical officer This table summarises the key characteristics of the health facilities within each of the HDSS All facilities at both sites provided HIV testing as well as PMTCT services, while 80% in Nairobi and 94% facilities in Kisumu offered HIV care and treatment services. In terms of human resources indicators, we see that the median numbers of healthcare workers per facility were higher in Nairobi compared to Kisumu. This is not surprising given the higher proportion of larger facilities in Nairobi and the relatively greater availability of medical personnel in the capital. NEXT SLIDE

Health facility characteristics   Nairobi Kisumu Total number of clinics (n(%)) 10 (100) 34 (100) HIV testing 100 PMTCT HIV care and treatment 80 94 HR indicators (median (range)) Clinicians* 2.5 (0-8) 1 (0 - 34.5) Nurses/midwives 6.5 (0 -18) 2 (0-62) HIV testing clients/week 78 (11-1237) 39 (0-206) Weekly HTC clients/staff+ 1.3 (0.8-42) 3.7 (0-41.2) No. ART clients/week 50 (35-141) 37 (0-154) No. weekly ART clients/ health worker 4.8 (3.3-8.8) 11.7 (0-38.5) *Doctor, clinical officer, assistant medical officer Furthermore, the median number of HIV testing and ART clients seen in the facilities each week was higher in Nairobi than in Kisumu But each staff member managed a higher number of patients per week in Kisumu compared to Nairobi

Implementation of HCT policies I’ll now present the results in terms of the implementation of HIV policiies relating to HIV testing, access to ART and retention in care. I’ll start with implementation of HIV testing policies. This slide shows a selection of 11 policy and practice indicators that we investigated relating to HIV testing and counseling. Explicit policies existed for all 11 indicators and the majority of policies were reported as widely implemented across both small and large facilities in Nairobi and Kisumu. However, there was partial or poor implementation of some HTC indicators despite the existence of explicit policy. For example, increasing HTC for high risk groups was highlighted as a priority area in the Kenya National AIDS Strategic Plan published in 2009. Also national guidelines state that vulnerable populations such as men who have sex with men, commercial sex workers and injecting drug users should be provided with tailored and equitable access to HIV testing and counseling. However, this was only implemented by 70% of facilities in Nairobo and 27% in Kisumu Other HTC policies that had partial or poor implementation included: Counsellors should assist no more than 15 clients per day - this applied to both settings. In Nairobi, quality of care reviews to be conducted twice per year - In Kisumu, repeat testing for pregnant women in their third trimester was only done in 47% of facilities Explicit, wide (>70%) Not explicit, wide (>70%) Explicit, partial (30-70%) Not explicit, partial (30-70%) Explicit, poor (<30%) Not explicit, poor (<30%)

Implementation of policies influencing ART access 10 policy and practice indicators were assessed in relation to access to ART. Overall, these national policies were explicit and their implementation was generally very high. The main exceptions were: Firstly that only 13% of facilities in Nairobi an 31% in Kisumu implemented the policy of ART initiation without requiring a full set of lab tests The other main exception to this was Option B+ which was only implemented in 20% of facilities in Nairobi and 6% in Kisumu, We should recall that these data are from 2013, and the implementation of Option B+ is likely to have evolved over the past 3 years. Explicit, wide (>70%) Not explicit, wide (>70%) Explicit, partial (30-70%) Not explicit, partial (30-70%) Explicit, poor (<30%) Not explicit, poor (<30%)

Implementation: Retention Finally, here are a selection of 10 indicators that we reviewed relating to retention in HIV care. Again, there were explicit policies for all these indicators Implementation was slightly better in the facilities in Kisumu, and notably we see that some facilities in Nairobi were not providing 3 monthly ART supplies to stable patients or conducting routine pill counts, despite policies to this effect. However, the number of facilities surveyed with ART provision in Nairobi was small. Explicit, wide (>70%) Not explicit, wide (>70%) Explicit, partial (30-70%) Not explicit, partial (30-70%) Explicit, poor (<30%) Not explicit, poor (<30%)

Mortality rate by facility type (Kisumu) Hospitals Finally, this graph shows the mortality rates among people living with HIV calculated as the number of deaths per 1000 person years in the Kisumu sites, in relation to the last clinic that they used before their death. Overall, we can see that with the overlapping confidence intervals, there are no real differences between the smaller facilities, larger facilities and hospitals. On the one hand this suggests that even small facilities are performing well, as you might expect higher mortality rates if the quality of care was poorer. It is also likely to reflect that many people will go to the larger facilities when they are very sick, and so it is not surprising that there is a higher rate of deaths among persons last attending those facilities

Discussion Overall, widespread implementation of most explicit HIV care and treatment policies in Nairobi and Kisumu HDSS Implementation notably stronger for policies relating to ART access and retention in care. Gaps: A few explicit policies relating to PMTCT and implementation of HIV testing policies were weak. In order to achieve 90-90-90 targets efforts to improve entry into care will be crucial. Limitation: ALPHA studies not nationally representative (but most health services in the study sites provided through national programmes) Policy review currently being updated to capture recent shifts (i.e. Option B+, test and treat etc.) and a second round of health facility surveys are underway. Overall, there was widespread implementation of most explicit HIV care and treatment policies in Nairobi and Kisumu HDSS Implementation was notably stronger for policies relating to ART access and retention in care. A few explicit policies relating to PMTCT and implementation of HIV testing policies were weakly implemented in 2013 – notably testing for key populations and Option B+. In order to achieve 90-90-90 targets efforts to improve entry into care will be crucial. One limitation of this study is that the ALPHA HDSS partner sites not nationally representative. However, most health services in the study sites are provided through national programmes The policy review currently being updated to capture recent shifts (i.e. Option B+, test and treat etc.) and a second round of health facility surveys are underway.

Acknowledgements Study participants and field workers for their time and contribution to the study Colleagues at KEMRI-CGHR in Kisumu, APHRC in Nairobi and the ALPHA Network at the London School of Hygiene and Tropical Medicine Finally, I woud just like to acknowledge… This study was made possible with support from: The Wellcome Trust (085477/Z/08/Z) The Bill and Melinda Gates Foundation (OPP1082114).