Decentralization of HIV care and treatment services in Central Province, Kenya: Adult patient characteristics and outcomes Presenting author: William Reidy, PhD Reidy W, Hawken M, Wang C, Koech E, Elul B, and Abrams EJ for the Identifying Optimal Models of HIV Care in Africa: Kenya Consortium

Background: Kenya Population: 38.6 million Adult HIV prevalence: 6.2% Living with HIV: 1.6 million Estimated annual number of newly infected: 100,000 Number died of AIDS- related causes in 2011: 49,126

Background: Decentralization of HIV care in Kenya HIV care/ART in Kenya was provided in a small number of secondary health facilities (HF): – District, sub-district, provincial, or teaching/national referral hospitals Beginning in 2004, started scaling up HIV clinics at smaller, primary HF: – Health centers and dispensaries Performance of primary HF during scale-up is not well- established

Objective To compare the performance of primary and secondary HF in Central Province, Kenya during a period of scale-up: – Patient volume – Patient and facility characteristics – Quality of care – Patient retention

Population and data sources 37 of 52 government health facilities in Central Province supported by ICAP at Columbia University via PEPFAR funding – 15 secondary and 22 primary HF Included patients enrolled between (N= 26,690) Data sources: – HIV care/ART data from patient-level databases maintained by facility staff – Annual facility survey conducted by ICAP

Key variables and outcomes (1) Patient volume – Number of patients enrolled in HIV care, by year Patient characteristics – Gender, age, WHO stage, CD4 count at enrollment and ART initiation Facility characteristics – Rural/non-rural, nurse ART provision, CD4 machine on-site

Key variables and outcomes (2) Quality of care – Assessment of ART eligibility (CD4/WHO), prompt ART initiation Patient retention 1.Death: Recorded as dead in facility database 2.Loss to follow-up: Not dead, not transferred out, and not attending clinic for >6 months for patients on ART, or >12 month for pre-ART patients

Analytic Methods Descriptive statistics Kaplan-Meier survival curves Competing risks regression (pre-ART) and Cox proportional hazards regression (ART)  Multivariate regression models included: site type (primary vs. secondary HF), WHO stage, CD4 count, age group, gender, year of patient enrollment in care or ART initiation

Results

Patient volume

Enrollment in HIV care and treatment at primary and secondary HF

# Primary HF # Secondary HF

Facility characteristics

Clinic location, nurse ART provision, and presence of CD4 machine on-site

Patient characteristics

Characteristics at enrollment in HIV care Primary HFSecondary HF (n=3,881)(n=22,809) Female72%69% Age group % %23% %42% 40+35%34% CD4 count40% missing41% missing <10025%31% % %20% %27% WHO stage11% missing24% missing I/II69%60% III/IV31%40%

Point of entry to HIV care Primary HF Secondary HF (n=3,881)(n=22,809) Transferred in20%12% VCT19%29% PMTCT12%9% TB/HIV5%6% PITC3%6% Unknown/other41%34%

Characteristics of patients starting ART Primary HFSecondary HF (n=2,391)(n=13,486) CD4 value at ART initiation19% missing18% missing <10032%38% % %26% 350+7%5% WHO stage at ART initiation13% missing18% missing I/II52% III/IV48%

Quality of care: ART eligibility assessment and prompt initiation

Patient retention: Death and loss to follow-up (LTF)

Death following enrollment in HIV care (pre-ART) Adjusted SHR= % CI: ( )

Adjusted SHR= % CI: ( ) LTF following enrollment in HIV care (pre-ART)

Death following ART initiation Adjusted HR= % CI: ( )

LTF following ART initiation Adjusted HR= % CI: ( )

Adjusted S/HR of non-retention in Primary vs. Secondary HF All patients Adjusted S/HR* 95% CI Pre-ARTDeath LTF ARTDeath LTF *Reference category: Secondary HF. Models control for WHO stage, CD4 count, age group, gender, year of patient enrollment in care or ART initiation

Adjusted S/HR of non-retention in Primary vs. Secondary HF Sensitivity analysis excluding transfer-in patients All patients Excluding transfer-in patients Adjusted S/HR* 95% CI Adjusted S/HR* 95% CI Pre-ARTDeath LTF ARTDeath LTF *Reference category: Secondary HF. Models control for WHO stage, CD4 count, age group, gender, year of patient enrollment in care or ART initiation

Summary Patient enrollment at primary HF increased dramatically during the period Patients enrolling in primary HF were somewhat healthier by WHO stage, CD4 count Quality of patient care and retention were comparable at primary and secondary HF – Among pre-ART patients, the rate of LTF was lower at primary than at secondary facilities Primary HF have performed well within the context of decentralization in Central Province, Kenya

Acknowledgements Kenya Ministry of Health Government staff at the 37 facilities ICAP staff in Kenya and in New York – Dr. Muhsin Sheriff (Kenya), Mansi Agarwal (NY) US Centers for Disease Control and Prevention The President’s Emergency Plan for AIDS Relief This research was supported by PEPFAR through the CDC under the terms of Cooperative Agreement Number 5U62PS and 5U2GPS001537