The relationship between adherence to clinic appointments and year-one mortality for newly enrolled HIV infected patients at a regional referral hospital in Western Kenya, January 2011-December 2012.

This retrospective cohort analysis was conducted to describe the association between adherence to clinic appointments and mortality, one year after enrollment into HIV care. We examined appointment-adherence for newly enrolled patients between January 2011 and December 2012 at a regional referral hospital in western Kenya. The outcomes of interest were patient default, risk factors for repeat default, and year-one risk of death. Of 582 enrolled patients, 258 (44%) were defaulters. GEE revealed that once having been defaulters, patients were significantly more likely to repeatedly default (OR 1.4; 95% CI 1.12-1.77), especially the unemployed (OR 1.43; 95% CI 1.07-1.91), smokers (OR 2.22; 95% CI 1.31-3.76), and those with no known disclosure (OR 2.17; 95% CI 1.42-3.3). Nineteen patients (3%) died during the follow-up period. Cox proportional hazards revealed that the risk of death was significantly higher among defaulters (HR 3.12; 95% CI 1.2-8.0) and increased proportionally to the rate of patient default; HR was 4.05 (95% CI1.38-11.81) and 4.98 (95% CI 1.45-17.09) for a cumulative of 4-60 and ≥60 days elapsed between all scheduled and actual clinic appointment dates, respectively. Risk factors for repeat default suggest a need to deliver targeted adherence programs.

Integrated community case management for childhood illnesses: explaining policy resistance in Kenya.

BACKGROUND: There has been a re-emphasis recently on community health workers to provide child health care services including integrated community case management for childhood illness (iCCM). This research analysed iCCM policy development in Kenya and in particular the types of decision-making criteria used by Kenyan policy-makers in considering whether to advance iCCM policy. METHOD: Data were collected through document reviews (n = 41) and semi-structured interviews (n = 19) with key stakeholders in iCCM policy including government officials, development partners, bilateral donors, and civil society organizations. Initial analysis was guided by the policy triangle with further analysis of factors affecting policy decision-making drawing upon a simple framework developed by Grindle and Thomas (Policy makers, policy choices and policy outcomes: the political economy of reform in developing countries. 1989; Policy Sci 22: :213-48.). FINDINGS: Policy development for iCCM has been slow in Kenya, compared with other Sub-Saharan African countries. At the time of the study, the Government had just completed the Community Health Training Manual which incorporated iCCM as a module, but this was the only formal expression of iCCM in Kenya. We found technical considerations, notably concerns about community health workers dispensing antibiotics to be a key factor slowing iCCM policy development, but this also overlapped with bureaucratic considerations, such as how the development of community health worker cadres may affect clinicians, as well as initial concerns about how an integrated approach might affect vertically oriented programs. International actors through agreements such as the Millennium Development Goals helped to get child survival onto the national policy agenda and such actors were active promoters of iCCM policy change. However international funders had not committed funding to scale-up iCCM policy, and this probably constrained their influence over iCCM policy debate. CONCLUSION: Kenyan actors' concerns about iCCM underline the importance of adapting global policies to local conditions, and also generating local evidence to inform decision-making.

The adult population impact of HIV care and antiretroviral therapy in a resource poor setting, 2003-2008.

OBJECTIVE: To describe the population uptake of HIV care including antiretroviral therapy (ART) and its impact on adult mortality in a rural area of western Kenya with high HIV prevalence during a period of rapid HIV services scale-up. DESIGN: Adult medical chart data were abstracted at health facilities providing HIV care/ART to residents of a Health and Demographic Surveillance System (HDSS) and linked with HDSS demographic and mortality data. METHODS: We evaluated secular trends in patient characteristics across enrollment years and estimated proportions of HIV-positive adult residents receiving care. We evaluated adult (18-64 years) population mortality trends using verbal autopsy findings. RESULTS: From 2003 to 2008, 5421 HDSS-resident adults enrolled in HIV care; 61.4% (n=3331) were linked to HDSS follow-up data. As the number of facilities expanded from 1 (2003) to 17 (2008), receipt of HIV services by HIV-positive residents increased from less than 1 to 29.5%, and ART coverage reached 64.0% of adults with CD4 cell count less than 250 cells/µl. The proportion of patients with WHO stage 4 at enrollment decreased from 20.4 to 1.9%, and CD4 cell count testing at enrollment increased from 1.0 to 53.4%. Population-level mortality rates for adults declined 34% for all causes, 26% for AIDS/tuberculosis, and 47% for other infectious diseases; noninfectious disease mortality rates remained constant. CONCLUSION: The initial years of rapid HIV service expansion coincided with a drop in adult mortality by a third. Continued expansion of population access to HIV clinical services, including ART, and program quality improvements will be necessary to achieve further progress in reducing HIV-related morbidity and mortality.