1. Mobile telemedicine for Community Health Worker HIV Care: A pilot study in Nairobi, Kenya Jennifer Cohn, MD MPH University of Pennsylvania School of Medicine

2. Background Scale up vs HCW shortage Use of CHW for HIV care WHO Task Shifting Report (2007) Evidence of health systems benefit Evidence of clinical benefit Country guidelines Challenges Poor clinical support of CHWs in field Poor linkage of CHIS to formal HIS Decroo et al, JAIDS 2010 MSF Khayelitsha programme report, 2011 WHO. Task shifting, 2007 Celletti et al., AIDS 2010

3. Background: Kenya HIV 1.6 million HIV 540,000 on ART Changing guidelines Health workforce shortage Nurses 1.18 per 1000 Doctors 0.14 per 1000 Kenya Community Health Strategy Developed 2006, roll-out 2009 Level 1 of the health system Aid in delivery of Kenya EHP Supports CHWs in a variety of tasks, links to an RN supervisor Link CHIS to HIS Interim reviews

4. The Pilot Study Goals Support CHW clinical-decision making Link CHIS to HIS Innovation Branched logic surveys Easy-to-use interface Real-time upload to server Aims Assess ability of CHWs to learn and use mHealth application Assess function and connectivity of server Assess patient outcomes (earlier return to clinic, clinician action). Setting Nairobi, Kenya Mbagathi District Hospital Subjects 17 CHWs Convenience sampling

5. The Pilot Study: Methods CHW activities 1 st line ART initiation 2 nd line ART initiation Defaulters Post-hospitalization Clinician request Training Standard 4 hour, didactic and role play 2 Facilitators Use for 6 weeks CHW Home Visit Collect and record patient information Transmit information to clinic Information to clinician Patient clinic visit ACTION!

6. The Pilot Study: Methods CHW activities 1 st line ART initiation 2 nd line ART initiation Defaulters Post-hospitalization Clinician request Training Standard 4 hour, didactic and role play 2 Facilitators Use for 6 weeks CHW Home Visit Collect and record patient information Transmit information to clinic Information to clinician Patient clinic visit ACTION!

7. Evaluation Tools Ability to learn and use technology Role play Time 0, 3 and 6 weeks Satisfaction Survey (Likert scale) Time 0 and 6 weeks Server function Server downtimes Failed uploads Patient outcomes Red flags Chart review

8. Results: CHW Demographics and Server Function Server Functioning Downtime: 1 episode lasting 33 hours Survey transmission 78 total 16 (20.5%) uploaded >24 hours 6 (7.7%) uploaded greater than 48 hours

9. Results: Role Play

10. Results: Satisfaction

11. Results: Red Flags

12. Results: Chart Review Charts reviewed 28 reviewed 34 not found 28 mismatched name/chart number Results 20 (71%) red flags (earlier visits) 6 (20%) CHW-instructed earlier visits Key indicators: Cough >2 weeks Adherence

13. Discussion Technology Minimal training requirements Quickly attained and maintained Good connection and server functionality Acceptance and satisfaction Clinical significance High numbers of red flags CHWs identify critical issues clinicians may not Limitations and next steps Small sample size, short follow-up period Inability to locate many charts Next steps: Push technology to link to clinicians

14. Thank You University of Pennsylvania Penn CFAR Greg Bisson, MD MSCE Nairobi, Kenya Khou Shong MPH Donata Muthoni Josephine Mwagiru IT team Debbie Theobald Adam Kundishora