Integration of HIV and Non-communicable Disease management into Primary Care in Nairobi, Kenya: Characteristics and Outcomes Jeffrey K. Edwards 1, Helen Bygrave 2, Rafael Van den Bergh 3, Walter Kizito 1, Erastus Cheti 1, Rose J. Kosgei 4, Agnès Sobry 1, Alexandra Vandenbulcke 1, Shobha N. Vakil 5, Tony Reid 3 1 Médecins Sans Frontières, Nairobi, Kenya 2 Médecins Sans Frontières, Southern Africa Medical Unit, Capetown, South Africa 3 Médecins Sans Frontières, Operational Centre, Brussels, Belgium 4 Department of Obstetrics and Gynaecology, University of Nairobi, Nairobi, Kenya 5 Kenya National AIDs and STI Control Program/HRH Capacity Bridge Project, Nairobi, Kenya

BACKGROUND – NON-COMMUNICABLE DISEASES  Non-communicable diseases (NCD) were declared a neglected global health issue by WHO in 2005  Globally, the burden of NCD is increasing yearly  NCD health care needs remain unmet, especially in resource-constrained settings such as Kibera: need for well defined integrated models of primary care lack of access to services lack of adequately trained staff & NCD guidelines medications remain expensive follow up is a major challenge

BACKGROUND: MSF Context  The Kibera slum in Nairobi, Kenya, is characterized by poverty, poor sanitation, and a highly mobile population  Such populations are vulnerable for NCD's, such as hypertension (HTN) and diabetes mellitus (DM), inaddition to HIV

BACKGROUND: NEW FOR MSF  In 2010, MSF integrated NCD care with the existing HIV programme in three primary health care clinics in the Kibera slum

The main components of the programme included: A holistic team of health staff (clinical officers, nurses, nutritionists, health educators, social workers and adherence counsellors) Offer of a package of care (clinical care, nutritional and social support, and education on life style measures, diseases and treatment) Cohort outcome data monitoring DESCRIPTION – PACKAGE OF CARE

 To describe the characteristics and outcomes of patients with NCDs (hypertension and/or diabetes) with or without HIV  To assess whether the patients’ health can be improved through an integrated model of primary care OBJECTIVE

 Study site: three MSF-supported clinics in Kibera  Study period: January 2010-June 2013  Study population: all patients ≥ 15 years diagnosed with HTN and/or DM: HTN: BP (>140/90) measurements recorded during two or more clinic visits DM: fasting blood sugar ≥7.0 mmol/l  Routinely collected data extracted from a program database  Ethics clearance from Kenya Medical Research Institute and MSF Ethics Review Board METHODS

RESULTS Patient characteristics at enrolment into chronic disease cohort Clinical Characteristics MaleFemale HIV+HIV–HIV+HIV– Number patients (%) n=2, (10)573 (90)144 (9)1423 (91) Median age years (IQR) 45 (39-53)53 (46-60) p< (38-50)47 (40-54) p<0.001 BMI (kg/m 2 )22 (20-24)24 (20-26) p= (22-28)28 (24-32) p< Systolic BP (mm Hg, IQR) 154 ( ) 160 ( ) p= ( ) 160 ( ) p< Diastolic BP (mm Hg, IQR) 97 (86-105)99 (89-108)97 (89-106) 100 (90-110) p=0.006

RESULTS Patient diagnosis at enrollment into chronic disease cohort Diagnosis MaleFemale HIV+HIV–HIV+HIV– Hypertension (stages 1-3*) p=0.004* p<0.001* Diabetes (type 1 & 2*) p=0.008* Chronic Kidney Disease-concurrent (CrCl < 60 ml/min)

RESULTS Characteristics of people living with HIV in chronic disease cohort Characteristic Male (IQR)Female (IQR) Median age (years) at HIV programme enrollment 43 (36-50)40 (34-46) Median CD4 count at NCD programme enrollment 476 ( )442 ( ) Median years in HIV programme 4 (3-6)5 (3-7) Median years on ART 4 (3-6)4 (2-6)

RESULTS Chronic kidney disease within the cohort The frequency of chronic kidney disease (CKD = creatinine clearance < 60 ml/min) in the combined cohort was 15% (266/1802) There were no differences between the frequency of CKD in people living with HIV (PLHIV) vs. those without HIV. Of those with CKD within the cohort, 15% (41/266) had concurrent Type 1 or 2 diabetes mellitus. There was no association found between the use of tenofovir and CKD among PLHIV. The median age for those with PLHIV and CKD was 47 (IQR ) vs. 59 (49-70) years without HIV (p < ).

RESULTS Selected outcomes from the chronic disease program, MaleFemale Outcomes (median)HIV+ (IQR)HIV– (IQR)HIV+ (IQR)HIV– (IQR) Systolic BP at last visit144 ( )148 ( )143 ( )143 ( ) Diastolic BP at last visit90 (79-97)88 (80-96)90 (81-98)88 (79-96) Last HbA1c in diabetics9 (7-10)9 (7-11)8 (5-12)9 (7-11) Last total cholesterol in diabetics 5 (5-6)5 (4-6)6 (5-7)5 (4-6) Number lost to follow up after 6 months or longer (%) 18/66 (27) 249/573 (44) p= /144 (24) 521/1423 (37) p=0.002

 Short-term monitoring of 3.5 years: no possibility to assess reduction in morbidity and mortality  Poor documentation of complications at baseline and during follow up LIMITATIONS

 This study provides a “real world” assessment of an integrated primary care program from an informal settlement  Standardized treatment protocols were used for hypertension, diabetes, CKD and HIV that were aligned with international guidelines  Program was primarily run by clinical officers and nursing staff  Routine data monitoring was completed Strengths

 This study highlights the need to recognize the increasing chronic disease burden in sub-Saharan Africa.  PLHA appear to be at higher risk of developing concurrent NCDs at a younger age, and would benefit from routine surveillance for them.  It is possible to integrate both HIV and NCD care together in a primary care programme  This integrated programme can be run by clinical officers and nursing staff within significant resource constraints. CONCLUSIONS

 A special thanks to the whole Kibera staff for their work and dedication  This research was supported through the Médecins Sans Frontières, Brussels-Luxembourg Operational Research Unit  Médecins Sans Frontières-Operational Centre Brussels brought technical support and complementary programme funds ACKNOWLEDGEMENTS

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