Gaussian process emulation to improve efficiency of computationally intensive multidisease models: a practical tutorial with adaptable R code.

BACKGROUND: The rapidly growing burden of non-communicable diseases (NCDs) among people living with HIV in sub-Saharan Africa (SSA) has expanded the number of multidisease models predicting future care needs and health system priorities. Usefulness of these models depends on their ability to replicate real-life data and be readily understood and applied by public health decision-makers; yet existing simulation models of HIV comorbidities are computationally expensive and require large numbers of parameters and long run times, which hinders their utility in resource-constrained settings. METHODS: We present a novel, user-friendly emulator that can efficiently approximate complex simulators of long-term HIV and NCD outcomes in Africa. We describe how to implement the emulator via a tutorial based on publicly available data from Kenya. Emulator parameters relating to incidence and prevalence of HIV, hypertension and depression were derived from our own agent-based simulation model and other published literature. Gaussian processes were used to fit the emulator to simulator estimates, assuming presence of noise for design points. Bayesian posterior predictive checks and leave-one-out cross validation confirmed the emulator's descriptive accuracy. RESULTS: In this example, our emulator resulted in a 13-fold (95% Confidence Interval (CI): 8-22) improvement in computing time compared to that of more complex chronic disease simulation models. One emulator run took 3.00 seconds (95% CI: 1.65-5.28) on a 64-bit operating system laptop with 8.00 gigabytes (GB) of Random Access Memory (RAM), compared to > 11 hours for 1000 simulator runs on a high-performance computing cluster with 1500 GBs of RAM. Pareto k estimates were < 0.70 for all emulations, which demonstrates sufficient predictive accuracy of the emulator. CONCLUSIONS: The emulator presented in this tutorial offers a practical and flexible modelling tool that can help inform health policy-making in countries with a generalized HIV epidemic and growing NCD burden. Future emulator applications could be used to forecast the changing burden of HIV, hypertension and depression over an extended (> 10 year) period, estimate longer-term prevalence of other co-occurring conditions (e.g., postpartum depression among women living with HIV), and project the impact of nationally-prioritized interventions such as national health insurance schemes and differentiated care models.

Tree-based subgroup discovery using electronic health record data: heterogeneity of treatment effects for DTG-containing therapies.

The rich longitudinal individual level data available from electronic health records (EHRs) can be used to examine treatment effect heterogeneity. However, estimating treatment effects using EHR data poses several challenges, including time-varying confounding, repeated and temporally non-aligned measurements of covariates, treatment assignments and outcomes, and loss-to-follow-up due to dropout. Here, we develop the subgroup discovery for longitudinal data algorithm, a tree-based algorithm for discovering subgroups with heterogeneous treatment effects using longitudinal data by combining the generalized interaction tree algorithm, a general data-driven method for subgroup discovery, with longitudinal targeted maximum likelihood estimation. We apply the algorithm to EHR data to discover subgroups of people living with human immunodeficiency virus who are at higher risk of weight gain when receiving dolutegravir (DTG)-containing antiretroviral therapies (ARTs) versus when receiving non-DTG-containing ARTs.

Predictors of Mortality Among Children and Adolescents Living With HIV on Antiretroviral Therapy in Western Kenya.

BACKGROUND: Antiretroviral therapy (ART) has decreased HIV-attributable deaths; however, children and adolescents continue to have high HIV-associated mortality. SETTING: We determined the predictors of death among children and young adolescents living with HIV (CALWH) who died while in care in Western Kenya. METHODS: This retrospective case-control study used electronically abstracted data of 6234 CALWH who received care in Academic Model Providing Access to Healthcare HIV clinics in Western Kenya between January 2002 and November 2022. The cases comprised CALWH who were reported dead by November 2022, while the controls constituted of matched CALWH who were alive and in care. Independent predictors of mortality were determined using univariable and multivariable Cox proportional hazard regression models. Kaplan-Meier analysis ascertained survival. RESULTS: Of the 6234 participants enrolled, slightly more than half were male (51.7%). The mean (SD) age at the start of ART was significantly lower in cases than in controls at 6.01 (4.37) and 6.62 (4.11) ( P < 0.001), respectively. An age of 11 years or older at start of ART (adjusted Hazard Ratio [aHR]: 8.36 [3.60-19.40]), both parents being alive (aHR: 3.06 [1.67-5.60]), underweight (aHR: 1.82 [1.14-2.92]), and World Health Organization stages 3 (aHR: 2.63 [1.12-6.18]) and 4 (aHR: 2.20 [0.94-5.18]) increased mortality; while school attendance (aHR: 0.12 [0.06-0.21]), high CD4 + counts >350 cells/mm 3 (aHR: 0.79 [0.48-1.29]), and low first viral load <1000 copies/mL (aHR: 0.24 [0.14-0.40]) were protective. CONCLUSION: Independent predictors of mortality were age 11 years or older at the start of ART, orphan status, underweight, and advanced HIV disease. Beyond the provision of universal ART, care accorded to CALWH necessitates optimization through tackling individual predictors of mortality.

Prevalence of lifestyle cardiovascular risk factors and estimated framingham 10-year risk scores of adults with psychotic disorders compared to controls at a referral hospital in Eldoret, Kenya.

INTRODUCTION: Lifestyle factors such as smoking, alcohol use, suboptimal diet, and inadequate physical activity have been associated with increased risk of cardiovascular diseases. There are limited data on these risk factors among patients with psychosis in low- and middle-income countries. OBJECTIVES: This study aimed to establish the prevalence of lifestyle cardiovascular risk factors, and the 10-year cardiovascular risk scores and associated factors in patients with psychosis compared to controls at Moi Teaching and Referral Hospital in Eldoret, Kenya. METHODS: A sample of 297 patients with schizophrenia, schizoaffective disorder, or bipolar mood disorder; and 300 controls matched for age and sex were included in this analysis. A study specific researcher-administered questionnaire was used to collect data on demographics, antipsychotic medication use, smoking, alcohol intake, diet, and physical activity. Weight, height, abdominal circumference, and blood pressure were also collected to calculate the Framingham 10-year Cardiovascular Risk Score (FRS), while blood was drawn for measurement of glucose level and lipid profile. Pearson's chi-squared tests and t-tests were employed to assess differences in cardiovascular risk profiles between patients and controls, and a linear regression model was used to determine predictors of 10-year cardiovascular risk in patients. RESULTS: Compared to controls, patients with psychosis were more likely to have smoked in their lifetimes (9.9% vs. 3.3%, p = 0.006) or to be current smokers (13.8% vs. 7%, p = 0.001). Over 97% of patients with psychosis consumed fewer than five servings of fruits and vegetables per week; 78% engaged in fewer than three days of vigorous exercise per week; and 48% sat for more than three hours daily. The estimated 10-year risk of CVD was relatively low in this study: the FRS in patients was 3.16, compared to 2.93 in controls. The estimated 10-year cardiovascular risk in patients was significantly associated with female sex (p = 0.007), older patients (p < 0.001), current tobacco smoking (p < 0.001), and metabolic syndrome (p < 0.001). CONCLUSION: In the setting of Eldoret, there is suboptimal physical exercise and intake of healthy diet among patients with psychosis and controls. While the estimated risk score among patients is relatively low in our study, these data may be useful for informing future studies geared towards informing interventions to promote healthy lifestyles in this population.

Are outpatient costs for hypertension and diabetes care affordable? Evidence from Western Kenya.

BACKGROUND: Diabetes and hypertension pose a significant socio-economic burden in developing countries such as Kenya, where financial risk-protection mechanisms remain inadequate. This proves to be a great barrier towards achieving universal health care in such settings unless mechanisms are put in place to ensure greater access and affordability to non-communicable disease (NCD) management services. AIM: This article aims to examine outpatient management services costs for patients with diabetes and hypertension attending public primary healthcare facilities. SETTING: The study was conducted in Busia and Trans-Nzoia counties in Western Kenya in facilities supported by the PIC4C project, between August 2020 and December 2020. METHODS: This cross-sectional survey included 719 adult participants. Structured interviewer-administered questionnaires were used to collect information on healthcare-seeking behaviour and associated costs. The annual direct and indirect costs borne by patients were computed by disease type and level of healthcare facility visited. RESULTS: Patients with both diabetes and hypertension incurred higher annual costs (KES 13 149) compared to those with either diabetes (KES 8408) or hypertension (KES 7458). Patients attending dispensaries and other public healthcare facilities incurred less direct costs compared to those who visited private clinics. Furthermore, a higher proportionate catastrophic healthcare expenditure of 41.83% was noted among uninsured patients. CONCLUSION: Despite this study being conducted in facilities that had an ongoing NCDs care project that increased access to subsidised medication, we still reported a substantially high cost of managing diabetes and hypertension among patients attending primary healthcare facilities in Western Kenya, with a greater burden among those with comorbidities.Contribution: Evidenced by the results that there is enormous financial burden borne by patients with chronic diseases such as hypertension and diabetes; we recommend that universal healthcare coverage that offers comprehensive care for NCDs be urgently rolled out alongside strengthening of lower-level public healthcare systems.

Types and Outcomes of Arrhythmias in a Cardiac Care Unit in Western Kenya: A Prospective Study.

Background: Sustained arrhythmias are frequently encountered in cardiac care units (CCU), but their types and outcomes in Africa are unknown. Studies from high-income countries suggest arrhythmias are associated with worse outcomes. Objectives: To determine the types and proportion of cardiac arrhythmias among patients admitted to the CCU at Moi Teaching and Referral Hospital (MTRH), and to compare 30-day outcomes between patients with and without arrhythmias at the time of CCU admission. Methods: We conducted a prospective study of a cohort of all patients admitted to MTRH-CCU between March and December 2021. They were stratified on the presence or absence of arrhythmia at the time of CCU admission, irrespective of whether it was the primary indication for CCU care or not. Clinical characteristics were collected using a structured questionnaire. Participants were followed up for 30 days. The primary outcome of interest was 30-day all-cause mortality. Secondary outcomes were 30-day all-cause readmission and length of hospital stay. The 30-day outcomes were compared between the patients with and without arrhythmia, with a p value < 0.05 being considered statistically significant. Results: We enrolled 160 participants. The median age was 46 years (IQR 31, 68), and 95 (59.4%) were female. Seventy (43.8%) had a diagnosis of arrhythmia at admission, of whom 62 (88.6%) had supraventricular tachyarrhythmias, five (7.1%) had ventricular tachyarrhythmias, and three (4.3%) had bradyarrhythmia. Atrial fibrillation was the most common supraventricular tachyarrhythmia (82.3%). There was no statistically significant difference in the primary outcome of 30-day mortality between those who had arrhythmia at admission versus those without: 32.9% versus 30.0%, respectively (p = 0.64). Conclusion: Supraventricular tachyarrhythmias were common in critically hospitalized cardiac patients in Western Kenya, with atrial fibrillation being the most common. Thirty-day all-cause mortality did not differ significantly between the group admitted with a diagnosis of arrhythmia and those without.

The Effect of HIV Treatment Interruption on Subsequent Immunological Response.

Recovery of CD4-positive T lymphocyte count after initiation of antiretroviral therapy (ART) has been thoroughly examined among people with human immunodeficiency virus infection. However, immunological response after restart of ART following care interruption is less well studied. We compared CD4 cell-count trends before disengagement from care and after ART reinitiation. Data were obtained from the East Africa International Epidemiology Databases to Evaluate AIDS (IeDEA) Collaboration (2001-2011; n = 62,534). CD4 cell-count trends before disengagement, during disengagement, and after ART reinitiation were simultaneously estimated through a linear mixed model with 2 subject-specific knots placed at the times of disengagement and treatment reinitiation. We also estimated CD4 trends conditional on the baseline CD4 value. A total of 10,961 patients returned to care after disengagement from care, with the median gap in care being 2.7 (interquartile range, 2.1-5.4) months. Our model showed that CD4 cell-count increases after ART reinitiation were much slower than those before disengagement. Assuming that disengagement from care occurred 12 months after ART initiation and a 3-month treatment gap, CD4 counts measured at 3 years since ART initiation would be lower by 36.5 cells/µL than those obtained under no disengagement. Given that poorer CD4 restoration is associated with increased mortality/morbidity, specific interventions targeted at better retention in care are urgently required.

Maternal and child health indicators in primary healthcare facilities: Findings in a health systems quasi-experimental study in western Kenya.

Background and purpose: Maternal and infant mortality are higher in low-income than in high-income countries due to weak health systems. The objective of this study was to improve access, utilization and quality of Maternal and Child Health care through a predesigned Enhanced Health Care System (EHC) that embodies the World Health Organization (WHO) pillars of the health system. Design and methodology: This study was conducted in two dispensaries in the Counties of Busia and Bungoma in Kenya as intervention sites and in four control clusters in Kakamega, Uasin Gishu, Trans Nzoia and Elgeyo Marakwet Counties. The study population was pregnant women and their children delivered over the study period in the intervention and control clusters.A quasi-experimental study design was used to conduct the study between 2015 and 2020 to compare the outcomes of the implementation of the EHC using the Find Link Treat and Retain (FLTR) strategy in one cluster, community owned initiatives in the other cluster and four control clusters at baseline and at the end of the study. A baseline survey was conducted in year one and an end line survey in the fifth year. Continuous data collection on maternal and childhood health indicators was done in all the six clusters and comparison made at the end of the study between the clusters. Results: We found a 26%, 10.3% and 0.8% increase in antenatal care (ANC) attendance in the intervention clusters of Obekai, Kabula and control clusters respectively. There was a 28.2%, 5.8% and 17.0% increase in attendance of 4+ ANC clinics of Obekai, Kabula and control clusters respectively. There was a 24% and 13% increase in Obekai and Kabula respectively in contraceptive use and a 2% decrease in contraceptive use in the control locations. There was a 38.2%, 25.6% and 34.7% increase in facility deliveries over the study period in Obekai, Kabula and control clusters respectively. There was a marked increase in immunization coverage in the intervention clusters of Obekai and Kabula compared to a significant decrease in control clusters for BCG, polio, pentavalent and measles. Conclusions and recommendations: In conclusion, use of the health systems approach in health care provision provides a holistic improvement in access and utilization of health services and in the improvement of health indicators.We do recommend that a systems approach be used in health services delivery to improve access, utilization and quality of health care provision at community and primary care levels.

Contraception use and HIV outcomes among women initiating dolutegravir-containing antiretroviral therapy in Kenya: a retrospective cohort study.

INTRODUCTION: The rollout of dolutegravir (DTG) in low- and middle-income countries was disrupted by a potential association reported with periconceptional DTG exposure among women living with HIV (WLHIV) and infant neural tube defects. This prompted countries to issue interim guidance limiting DTG use among women of reproductive potential to those on effective contraception. Data to understand the potential impact of such guidance on WLHIV are limited. METHODS: We conducted a retrospective cohort analysis of WLHIV 15-49 years initiating DTG-containing antiretroviral treatment (ART) in Kenya from 2017 to 2020. We determined baseline effective (oral, injectable or lactational amenorrhea) and very effective (implant, intrauterine device or female sterilization) contraception use among women who initiated DTG before (Group 1) or during (Group 2) the interim guideline period. We defined incident contraception use in each group as the number of contraceptive methods initiated ≤180 days post-guideline (Group 1) or post-DTG initiation (Group 2). We determined the proportions of all women who switched from DTG- to non-nucleoside reverse transcriptase inhibitor (NNRTI)- (efavirenz or nevirapine) containing ART ≤12 months post-DTG initiation, compared their viral suppression (<1000 copies/ml) and conducted multivariable logistic regression to determine factors associated with switching from DTG to NNRTI-containing ART. RESULTS: Among 5155 WLHIV in the analysis (median age 43 years), 89% initiated DTG after transitioning from an NNRTI. Baseline effective and very effective contraception use, respectively, by the group were: Group 1 (12% and 13%) and Group 2 (41% and 35%). Incident contraception use in each group was <5%. Overall, 498 (10%) women switched from DTG to an NNRTI. Viral suppression among those remaining on DTG versus switched to NNRTI was 95% and 96%, respectively (p = 0.63). In multivariable analysis, incident effective and very effective contraception use was not associated with switching. CONCLUSIONS: Baseline, but not incident, effective contraception use was higher during the interim guideline period compared to before it, suggesting women already using effective contraception were preferentially selected to initiate DTG after the guideline was released. These findings reveal challenges in the implementation of policy which ties antiretroviral access to contraceptive use. Future guidance should capture nuances of contraception decision-making and support women's agency to make informed decisions.

Continuity of Care is Associated with Higher Appointment Adherence Among HIV Patients in Low Clinician-to-Patient Ratio Facilities in Western Kenya.

We sought to determine the relationship between continuity of care and adherence to clinic appointments among patients receiving HIV care in high vs. low clinician-to-patient (C:P) ratios facilities in western Kenya. This retrospective analysis included 12,751 patients receiving HIV care from the Academic Model Providing Access to Healthcare (AMPATH) program, between February 2016-2019. We used logistic regression analysis with generalized estimating equations to estimate the relationship between continuity of care (two consecutive visits with the same provider) and adherence to clinic appointments (within 7 days of a scheduled appointment) over time. Adjusting for covariates, patients in low C:P ratio facilities who had continuity of care, were more likely to be adherent to their appointments compared to those without continuity (adjusted odds ratio = 1.50; 95% confidence interval, 1.33-1.69). Continuity in HIV care may be a factor in clinical adherence among patients in low C:P ratio facilities and should therefore be promoted.

Network characteristics of a referral system for patients with hypertension in Western Kenya: results from the Strengthening Referral Networks for Management of Hypertension Across the Health System (STRENGTHS) study.

BACKGROUND: Health system approaches to improve hypertension control require an effective referral network. A national referral strategy exists in Kenya; however, a number of barriers to referral completion persist. This paper is a baseline assessment of a hypertension referral network for a cluster-randomized trial to improve hypertension control and reduce cardiovascular disease risk. METHODS: We used sociometric network analysis to understand the relationships between providers within a network of nine geographic clusters in western Kenya, including primary, secondary, and tertiary care facilities. We conducted a survey which asked providers to nominate individuals and facilities to which they refer patients with controlled and uncontrolled hypertension. Degree centrality measures were used to identify providers in prominent positions, while mixed-effect regression models were used to determine provider characteristics related to the likelihood of receiving referrals. We calculated core-periphery correlation scores (CP) for each cluster (ideal CP score = 1.0). RESULTS: We surveyed 152 providers (physicians, nurses, medical officers, and clinical officers), range 10-36 per cluster. Median number of hypertensive patients seen per month was 40 (range 1-600). While 97% of providers reported referring patients up to a more specialized health facility, only 55% reported referring down to lower level facilities. Individuals were more likely to receive a referral if they had higher level of training, worked at a higher level facility, were male, or had more job experience. CP scores for provider networks range from 0.335 to 0.693, while the CP scores for the facility networks range from 0.707 to 0.949. CONCLUSIONS: This analysis highlights several points of weakness in this referral network including cluster variability, poor provider linkages, and the lack of down referrals. Facility networks were stronger than provider networks. These shortcomings represent opportunities to focus interventions to improve referral networks for hypertension. TRIAL REGISTRATION: Trial Registered on ClinicalTrials.gov NCT03543787 , June 1, 2018.

Impact of an Enhanced Patient Care Intervention on Viral Suppression Among Patients Living With HIV in Kenya.

BACKGROUND: Effective patient-centered interventions are needed to promote patient engagement in HIV care. We assessed the impact of a patient-centered intervention referred to as enhanced patient care (EPC) on viral suppression among unsuppressed patients living with HIV in Kenya. SETTING: Two rural HIV clinics within the Academic Model Providing Access to Health care. METHODS: This was a 6-month pilot randomized control trial. The EPC intervention incorporated continuity of clinician-patient relationships, enhanced treatment dialog, and improved patients' clinic appointment scheduling. Provider-patient communication training was offered to all clinicians in the intervention site. We targeted 360 virally unsuppressed patients: (1) 240 in the intervention site with 120 randomly assigned to provider-patient communication (PPC) training + EPC and 120 to PPC training + standard of care (SOC) and (2) 120 in the control site receiving SOC. Logistic regression analysis was applied using R (version 3.6.3). RESULTS: A total of 328 patients were enrolled: 110 (92%) PPC training + EPC, 110 (92%) PPC training + SOC, and 108 (90%) SOC. Participants' mean age at baseline was 48 years (SD: 12.05 years). Viral suppression 6 months postintervention was 84.4% among those in PPC training + EPC, 83.7% in PPC training + SOC, and 64.4% in SOC ( P ≤ 0.001). Compared with participants in PPC training + EPC, those in SOC had lower odds of being virally suppressed 6 months postintervention (odds ratio = 0.36, 95% confidence interval: 0.18 to 0.72). CONCLUSIONS: PPC training may have had the greatest impact on patient viral suppression. Hence, adequate training and effective PPC implementation strategies are needed.

Harmful Alcohol Use Among Healthcare Workers at the Beginning of the COVID-19 Pandemic in Kenya.

Background: Healthcare workers play a key role in responding to pandemics like the on-going COVID-19 one. Harmful alcohol use among them could result in inefficiencies in health service delivery. This is particularly concerning in sub-Saharan Africa where the health workforce is already constrained. The aim of this study is to document the burden and correlates of harmful alcohol use among healthcare workers at the beginning of the COVID-19 pandemic in Kenya with the aim of informing policy and practice. Methods: This study was a cross-sectional analysis of data obtained from a parent online survey that investigated the burden and factors associated with mental disorders among healthcare workers during the COVID-19 pandemic in Kenya. We analyzed data obtained from a sub-population of 887 participants who completed the Alcohol Use Disorder Identification Test questionnaire. We used descriptive statistics to summarize the socio-demographic characteristics of the participants and multivariate analysis to determine the factors associated with harmful alcohol use. Results: Three hundred and eighty nine (43.9%) participants reported harmful alcohol use. The factors significantly associated with increased odds of endorsing harmful alcohol use were: being male (AOR = 1.56; 95% CI = 1.14, 2.14; p = 0.006), being unmarried (AOR = 2.06; 95% CI = 1.48, 2.89; p < 0.001), having 11-20 years of experience as compared to having 20+ years of experience (AOR = 1.91; 95% CI = 1.18, 3.12; p = 0.009), and being a specialist (AOR = 2.78; CI = 1.64, 4.78; p = < 0.001) or doctor (AOR = 2.82; 95% CI = 1.74, 4.63; p < 0.001) as compared to being a nurse. Conclusions: A high proportion of healthcare workers reported harmful alcohol use at the beginning of the COVID-19 pandemic in Kenya. Males, the unmarried, those with 11-20 years of experience in the health field, doctors and specialists, were more likely to report harmful alcohol use. These findings highlight the need to institute interventions for harmful alcohol use targeting these groups of healthcare workers in Kenya during the COVID-19 pandemic in order to optimize functioning of the available workforce.

Incorporating respondent-driven sampling into web-based discrete choice experiments: preferences for COVID-19 mitigation measures.

To slow the spread of COVID-19, most countries implemented stay-at-home orders, social distancing, and other nonpharmaceutical mitigation strategies. To understand individual preferences for mitigation strategies, we piloted a web-based Respondent Driven Sampling (RDS) approach to recruit participants from four universities in three countries to complete a computer-based Discrete Choice Experiment (DCE). Use of these methods, in combination, can serve to increase the external validity of a study by enabling recruitment of populations underrepresented in sampling frames, thus allowing preference results to be more generalizable to targeted subpopulations. A total of 99 students or staff members were invited to complete the survey, of which 72% started the survey (n = 71). Sixty-three participants (89% of starters) completed all tasks in the DCE. A rank-ordered mixed logit model was used to estimate preferences for COVID-19 nonpharmaceutical mitigation strategies. The model estimates indicated that participants preferred mitigation strategies that resulted in lower COVID-19 risk (i.e. sheltering-in-place more days a week), financial compensation from the government, fewer health (mental and physical) problems, and fewer financial problems. The high response rate and survey engagement provide proof of concept that RDS and DCE can be implemented as web-based applications, with the potential for scale up to produce nationally-representative preference estimates.

Hepatitis C-related knowledge, attitudes and perceived risk behaviours among people who inject drugs in Kenya: A qualitative study.

Despite disproportionately high rates of Hepatitis C (HCV) among people who inject drugs (PWID) in low- and middle-income countries (LMICs), understanding of HCV-related knowledge, attitudes and perceived risk behaviours among this population remains limited. We aimed to elucidate knowledge, attitudes and experiences that could minimise transmission risk and maximise HCV treatment engagement among PWID in Kenya following the integration of HCV screening and education with needle and syringe programmes in drop-in-centres (DICs). We recruited 40 PWID with chronic HCV attending DICs in Nairobi and Coastal Kenya. Semi-structured interviews revealed a general understanding of HCV and awareness of HCV risk behaviours among participants; however, many felt limited control over their transmission risk due to factors such as 'local doctors', or individuals who perform a high volume of high-risk injections. Financial barriers, distance to clinic, poor health status and HCV-related stigma were all noted as barriers to HCV treatment. In conclusion, basic knowledge of and motivation for HCV treatment among PWID accessing DICs in Kenya was high; however, structural barriers and stigma complicate access to care. Local education programmes can address knowledge gaps, and behavioural and structural interventions can maximise the impact of HCV care in LMICs.

Improving maternal and child health outcomes through a community involvement strategy in Kabula location, Bungoma County, Kenya.

Background: Maternal, fetal and neonatal mortality are higher in low-income compared to high-income countries due to weak health systems including poor access and utilization of health services. Despite enormous recent improvements in maternal, neonatal and under five children health indicators, more rapid progress is needed to meet the targets including the Sustainable Development Goal 3(SDG). In Kenya these indicators are still high and comprehensive systems are needed to attain these goals. Objective: To facilitate innovative partnerships in health care provision and to assess trends in access, utilization and quality of Maternal and Child Health care through the health systems approach using community owned initiatives including use of community owned resourse persons (CORPs), establishment of Community Based Organisations (CBOs) and Income Generating Activities(IGAs). Study site: This was implemented in Kabula location, Bungoma County, Kenya between January 2016 and April 2019. Study population: Pregnant women, newborns and under-five children living in Kabula location identified by Community Owned Resource Persons (CORPs). Methods: A prospective study to show trends in maternal, neonatal and infant outcomes through the implementation of community owned initiatives. Findings: General, under five and antenatal clinic attendance increased four fold in 2016,2017 and 2018. There was a 76% full immunization coverage with 97% BCG and 84% Polio coverage respectively among children studied. There was an 87% facility delivery rate among the pregnant women enrolled in the study. Conclusions: Trends in Maternal and under-five health indicators in Kabula showed improvements over the study period following the implementation of the community owned initiatives and community participation. Recommendations: The community owned initiatives as implemented in this study is useful in primary care and universal health coverage programs in health care delivery systems in LMICs.

Higher Clinician-Patient Communication Is Associated With Greater Satisfaction With HIV Care.

Provider-patient communication (PPC) skills are key in promoting patient satisfaction. Our study examined the relationship between clinician PPC skills and patient satisfaction with care among virally unsuppressed adult HIV patients in Busia County, Kenya. This cross-sectional study was conducted among 360 HIV patients on first line antiretroviral regimen and having a recent viral load ≥400 copies HIV RNA/ml. We conducted logistic regression analysis. The mean age of participants was 48.2 years [standard deviation (SD): 12.05]. Overall, the mean score on clinician PPC skills was 33.3 (SD: 9.0). A high proportion (85%) of participants reported satisfaction with the HIV care services. After adjusting for covariates, the odds of being satisfied with care increased by 19% (adjusted odds ratio: 1.19, 95% CI: 1.11-1.30) for every one unit increase in the clinician PPC skills score. Promoting good PPC skills may be key to improving patient satisfaction with HIV care.

Mental Disorders Among Health Care Workers at the Early Phase of COVID-19 Pandemic in Kenya; Findings of an Online Descriptive Survey.

Background: Healthcare workers responding to the Corona Virus Pandemic (COVID-19) are at risk of mental illness. Data is scanty on the burden of mental disorders among Kenyan healthcare workers responding to the pandemic that can inform mental health and psychosocial support. The purpose of this study was to establish the frequency and associated factors of worry, generalized anxiety disorder, depression, posttraumatic stress disorder and poor quality of sleep among Kenyan health care workers at the beginning of COVID-19 pandemic. Methods: We conducted an online survey among 1,259 health care workers in Kenya. A researcher developed social demographic questionnaire and several standardized tools were used for data collection. Standardized tools were programmed into Redcap, (Research Electronic Data Capture) and data analysis was performed using R Core Team. In all analysis a p-value < 0.05 was considered significant. Results: 66% of the participants reported experiencing worry related to COVID-19. 32.1% had depression, 36% had generalized anxiety, 24.2% had insomnia and 64.7% scored positively for probable Post Traumatic Stress Disorder (PTSD). Depression was higher among females compared to men (36.5 vs. 26.9%, p = 0.003), workers <35 years old compared to older ones (38.1 vs. 26.4%, p < 0.001), and those who were not married compared to those who were married (40.6 vs. 27.6%, p < 0.001). Generalized anxiety was commoner among workers aged <35 years (43.5 vs. 29.3%, p < 0.001), females (41.7 vs. 29.2%, p < 0.001), those who mere not married compared to the married (45.2 vs. 31.2%, p < 0.001) and those with <10 years working experience (41.6 to 20.5%, p < 0.001). Younger health care professional had a higher proportion of insomnia compared to the older ones (30.3 vs. 18.6%, p < 0.001). Insomnia was higher among those with <10 years' experience compared to those with more than 20 years' experience(27.3 vs. 17.6%, p = 0.043) Conclusion: Many Kenyan healthcare workers in the early phase of COVID-19 pandemic suffered from various common mental disorders with young, female professionals who are not married bearing the bigger burden. This data is useful in informing interventions to promote mental and psychosocial wellbeing among Kenyan healthcare workers responding to the pandemic.