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Wexler C, Maloba M, Mokua S, Babu S, Maosa N, Staggs V, Goggin K, Acharya H, Hurley EA, Finocchario-Kessler S. Assessing COVID-related concerns and their impact on antenatal and delivery care among pregnant women living with HIV in Kenya: a brief report. BMC Pregnancy Childbirth 2024; 24:46. [PMID: 38195390 PMCID: PMC10775612 DOI: 10.1186/s12884-023-06216-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 12/20/2023] [Indexed: 01/11/2024] Open
Abstract
BACKGROUND Some studies indicate that pregnant Kenyan women were concerned about Coronavirus disease 2019 (COVID-19) exposure during maternity care. We assessed concern regarding COVID-19 exposure and any impact on antenatal care (ANC) enrollment and/or hospital delivery among pregnant women living with human immunodeficiency virus (HIV) in Kenya. METHODS Data were collected from 1,478 pregnant women living with HIV enrolled in prevention of mother to child transmission of HIV (PMTCT) care at 12 Kenyan hospitals from October 2020 to July 2022. Surveys were conducted when women first presented for PMTCT services at the study hospital and asked demographic questions as well as items related to concerns about COVID-19. A 5-point Likert scale (strongly disagree to strongly agree) assessed concerns about COVID-19 exposure and travel challenges. Gestational age at PMTCT enrollment, number of ANC appointments attended, and delivery location were compared among women who expressed COVID-19 concerns and those who did not. RESULTS Few women reported delaying antenatal care (4.7%), attending fewer antenatal care appointments (5.0%), or having concerns about a hospital-based delivery (7.7%) because of COVID-19. More (25.8%) reported travel challenges because of COVID-19. There were no significant differences in gestational age at enrollment, number of ANC appointments, or rates of hospital-based delivery between women with concerns about COVID-19 and those without, CONCLUSION: Few pregnant women living with HIV expressed concerns about COVID-19 exposure in the context of routine ANC or delivery care. Women with and without concerns had similar care seeking behaviors. The recognized importance of routine ANC care and facility-based deliveries may have contributed to these positive pregnancy indicators, even among women who worried about COVID-19 exposure. TRIAL REGISTRATION www. CLINICALTRIALS gov identifier NCT04571684.
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Affiliation(s)
| | - May Maloba
- Global Health Innovations, Nairobi, Kenya
| | - Sharon Mokua
- Kenya Medical Research Institute, Nairobi, Kenya
| | | | | | - Vincent Staggs
- Health Services and Outcomes Research, Children's Mercy Kansas City, Kansas, USA
| | - Kathy Goggin
- Health Services and Outcomes Research, Children's Mercy Kansas City, Kansas, USA
- University of Missouri - Kansas City Schools of Medicine and Pharmacy, Kansas, USA
| | | | - Emily A Hurley
- Health Services and Outcomes Research, Children's Mercy Kansas City, Kansas, USA
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Sliefert M, Maloba M, Wexler C, Were F, Mbithi Y, Mugendi G, Maliski E, Nicolay Z, Thomas G, Kale S, Maosa N, Finocchario-Kessler S. Challenges with pediatric antiretroviral therapy administration: Qualitative perspectives from caregivers and HIV providers in Kenya. PLoS One 2024; 19:e0296713. [PMID: 38194419 PMCID: PMC10775971 DOI: 10.1371/journal.pone.0296713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 12/15/2023] [Indexed: 01/11/2024] Open
Abstract
BACKGROUND Current formulations of pediatric antiretroviral therapy (ART) for children with HIV present significant barriers to adherence, leading to drug resistance, ART ineffectiveness, and preventable child morbidity and mortality. Understanding these challenges and how they contribute to suboptimal adherence is an important step in improving outcomes. This qualitative study describes how regimen-related challenges create barriers to adherence and impact families. METHODS We conducted key informant interviews (KIIs) with 30 healthcare providers and 9 focus group discussions (FGDs) with a total of 72 caregivers, across three public hospitals in Siaya and Mombasa Kenya. The KIIs and FGDs were audio recorded, translated, and transcribed verbatim. The transcripts were hand coded based on emergent and a-priori themes. RESULTS Caregivers discussed major regimen-related challenges to adherence included poor palatability of current formulations, complex preparation, and administration (including measuring, crushing, dissolving, mixing), complex drug storage, and frequent refill appointments and how these regimen-related challenges contributed to individual and intrapersonal barriers to adherence. Caregivers discussed how poor taste led to child anxiety, refusal of medications, and the need for caregivers to use bribes or threats during administration. Complex preparation led to concerns and challenges about maintaining privacy and confidentiality, especially during times of travel. Providers corroborated this patient experience and described how these challenges with administration led to poor infant outcomes, including high viral load and preventable morbidity. Providers discussed how the frequency of refills could range from every 2 weeks to every 3 months, depending on the patient. Caregivers discussed how these refill frequencies interrupted work and school schedules, risked unwanted disclosure to peers, required use of financial resources for travel, and ultimately were a challenge to adherence. CONCLUSION These findings highlight the need for improved formulations for pediatric ART to ease the daily burden on caregivers and children to increase adherence, improve child health, and overall quality of life of families.
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Affiliation(s)
- Michala Sliefert
- University of Kansas Medical Center, Kansas City, KS, United States of America
| | - May Maloba
- Global Health Innovations, Nairobi, Kenya
| | - Catherine Wexler
- University of Kansas Medical Center, Kansas City, KS, United States of America
| | | | | | | | - Edward Maliski
- Oak Therapeutics, Lawrence, KS, United States of America
| | | | - Gregory Thomas
- University of Kansas, Lawrence, KS, United States of America
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Wexler C, Maloba M, Sliefert M, Babu S, Maosa N, Maliski E, Nicolay Z, Were F, Mbithi Y, Mugendi G, Thomas G, Acharya H, Finocchario-Kessler S. Assessing user preferences for design characteristics of oral dissolvable strips for pediatric HIV medication: a qualitative study. BMC Health Serv Res 2023; 23:1103. [PMID: 37845699 PMCID: PMC10580521 DOI: 10.1186/s12913-023-10078-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 09/27/2023] [Indexed: 10/18/2023] Open
Abstract
BACKGROUND Current infant antiretroviral therapy formulations pose barriers to daily adherence due to complex weight-based dosing, conspicuous preparation, and poor palatability. These adherence barriers jeopardize adherence, making patients vulnerable to virologic failure, development of drug resistance, and preventable mortality. Our team has previously established proof-of-principle for multi-drug oral dissolvable strips as alternative pediatric antiretroviral formulations with the potential to overcome these challenges and improve pediatric ART adherence and outcomes. The objective of this study was to assess caregiver and provider preferences for oral dissolvable strips and its packaging to inform its development. METHODS Guided by concepts of user-centered design, we conducted key informant interviews with 30 HIV care providers and focus group discussions targeting caregivers of children < 10 years of age living with HIV at 3 Kenyan hospitals. Key informant interviews and focus group discussions were audio recorded, translated/transcribed verbatim, and hand coded for a-priori and emergent themes. RESULTS A total of 30 providers and 72 caregivers (caring for 83 children, aged 5 months to 18 years) participated in the study. Caregivers and providers expressed a strong desire for an easier way to administer medication, especially among children too young to swallow tablets whole, and expressed enthusiasm around the idea of oral dissolvable strips. Key preferences included a pleasant taste; one strip per dose; small size with rapid dissolution; clear markings and instructions; and no special storage requirements. For packaging, stakeholders preferred individually wrapped strips within a dispenser. The individual packaging should be durable, waterproof, and easy to dispose of in communal spaces. They should also be easy to open, with clear indications where to open. The packaging holding the strips should be durable, re-usable, accommodating of various refill frequencies, and easy to use for children as young as 6. DISCUSSION The concept of oral dissolvable strips was highly acceptable to caregivers of children living with HIV and HIV care providers. By engaging stakeholders in an iterative design process starting from the early phases of design and development, we will maximize the likelihood of developing a product that is acceptable to the caregiver and infant, therefore leading to sustainable adherence.
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Affiliation(s)
- Catherine Wexler
- Department of Family Medicine, University of Kansas Medical Center, Kansas City, KS, USA.
| | - May Maloba
- Global Health Innovations, Nairobi, Kenya
| | - Michala Sliefert
- School of Medicine, University of Kansas Medical Center, Kansas City, KS, USA
| | | | | | | | | | | | | | | | - Gregory Thomas
- School of Architecture and Design, University of Kansas, Lawrence, KS, USA
| | - Harshdeep Acharya
- Department of Family Medicine, University of Kansas Medical Center, Kansas City, KS, USA
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Finocchario-Kessler S, Goggin K, Wexler C, Maloba M, Gautney B, Khamadi S, Lwembe R, Babu S, Sweat M. Incorporating the HIV Infant Tracking System into standard-of-care early infant diagnosis of HIV services in Kenya: a cost-effectiveness analysis of the HITSystem randomised trial. Lancet Glob Health 2023; 11:e1217-e1224. [PMID: 37474229 PMCID: PMC10482001 DOI: 10.1016/s2214-109x(23)00216-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 04/11/2023] [Accepted: 04/27/2023] [Indexed: 07/22/2023]
Abstract
BACKGROUND The HITSystem efficacy trial showed significant improvements in early infant diagnosis retention, return and notification of infant test results, and earlier antiretroviral therapy (ART) initiation compared with standard-of-care early infant diagnosis services in Kenya. This study aimed to analyse data from the HITSystem trial to assess the cost-effectiveness of the intervention in Kenya. METHODS In this analysis, we extrapolated results from the HITSystem cluster randomised controlled trial to model early infant diagnosis outcomes and cost-effectiveness if the HITSystem was scaled up nationally in Kenya, compared with standard-of-care outcomes. We used a micro-costing method to collect cost data, which were analysed from a health-system perspective, reflecting the investment required to add HITSystem to existing early infant diagnosis services and infrastructure. The base model used to calculate cost-effectiveness was deterministic and calculated the progression of infants through early infant diagnosis. Differences in progression across study arms were used to establish efficacy outcomes. The number of life-years gained per infant successfully initiating ART were based on the Cost Effectiveness of Preventing AIDS Complications model in east Africa. HITSystem cost data were integrated into the model, and the incremental cost-effectiveness ratio was calculated in terms of cost per life-year gained. Sensitivity analyses were done using the deterministic model with triangular stochastic probability functions for key model parameters added. The number of life-years gained was discounted at 3% and costs were adjusted to 2021 values. FINDINGS The cost per life-year gained from the HITSystem was US$82·72. Total cost for national HITSystem coverage in Kenya was estimated to be around $2·6 million; covering 82 230 infants exposed to HIV at a cost of $31·38 per infant and a yield of 1133 infants receiving timely ART, which would result in 31 189 life-years gained. With sensitivity analyses, the cost per life-year gained varied from $40·13 to $215·05. 90% of model values across iterations ranged between $55·58 (lower 5% threshold) and $132·38 (upper 95% threshold). INTERPRETATION The HITSystem would be very cost-effective in Kenya and can optimise the return on the existing investment in the national early infant diagnosis programme. FUNDING The US National Institute of Child Health and Human Development.
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Affiliation(s)
- Sarah Finocchario-Kessler
- Department of Family Medicine and Community Health, University of Kansas Medical Center, Kansas City, KS, USA.
| | - Kathy Goggin
- Health Services and Outcomes Research, Department of Pediatrics, Children's Mercy Hospital, Kansas City, MO, USA
| | - Catherine Wexler
- Department of Family Medicine and Community Health, University of Kansas Medical Center, Kansas City, KS, USA
| | - May Maloba
- Global Health Innovations Kenya, Nairobi, Kenya
| | | | - Samoel Khamadi
- Centre for Virus Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Raphael Lwembe
- Centre for Virus Research, Kenya Medical Research Institute, Nairobi, Kenya
| | | | - Michael Sweat
- Division of Global and Community Health, Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC, USA
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Wexler C, Dixon KS, Oyowe K, Lapke B, Conner H, Shoemaker H, Corriveau E, Greiner A, Finocchario-Kessler S. Development and evaluation of a COVID tracking system to support provision of social service in Wyandotte County, Kansas. Front Public Health 2023; 11:1035319. [PMID: 37427281 PMCID: PMC10326267 DOI: 10.3389/fpubh.2023.1035319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 06/01/2023] [Indexed: 07/11/2023] Open
Abstract
Background In addition to the state-mandated case investigation and contact tracing, the Unified Government Public Health Department of Wyandotte County, Kansas implemented social support services for COVID-19 cases and contacts; however, did not have the systems in place to document the provision of these services. Our team worked with the health department to develop and implement the COVID Tracking System (CTS), an eHealth system that linked multiple involved teams. Here, we describe the development and evaluation of the CTS. The objective of this manuscript is to describe and evaluate the development and implementation process of the Covid Tracking System. Methods Drawing from concepts of user-centered design, we took a 4-phase approach to development: understanding context, specifying needs, designing solutions, and evaluating. A mixed-methods evaluation of the development and implementation process using RE-AIM was conducted. Quantitative CTS data captured between February 1, 2021, and September 30, 2021 were exported. Descriptive statistics were calculated for categorical variables and means (SD, range) or median (IQR) for continuous variables. Qualitative discussions with key users supplemented the quantitative data. Results There were 1,152 cases entered into the CTS, of whom 307 (26.6%) requested a letter be sent to their workplace to excuse them during their quarantine period, 817 (70.9%) requested and had food and cleaning supplies delivered, 21 (1.8%) requested guidance on applying for federal assistance, and 496 (43.1%) requested to be contacted by a community health worker. While a few technical glitches slowed down early implementation, these were quickly resolved and key users felt that the CTS streamlined client referral and simplified their workflow, allowing them to spend more time on patient care and follow up, rather than documentation. After study implementation ended, the Unified Government Public Health Department of Wyandotte County continued using the CTS for client tracing and follow up. Discussion This project provides a roadmap of how user centered design can be applied to the development and evaluation of eHealth software to support program intervention implementation, even in situations where urgent action is needed.
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Affiliation(s)
- Catherine Wexler
- Department of Family Medicine, University of Kansas Medical Center, Kansas City, KS, United States
| | - Katelyn Sanner Dixon
- School of Medicine, University of Kansas Medical Center, Kansas City, KS, United States
| | - Kevin Oyowe
- Global Health Innovations–Kenya, Nairobi, Kenya
| | - Brooke Lapke
- School of Medicine, University of Kansas Medical Center, Kansas City, KS, United States
| | - Hannah Conner
- Unified Government of Wyandotte County Health Department, Kansas City, KS, United States
| | - Hailey Shoemaker
- Unified Government of Wyandotte County Health Department, Kansas City, KS, United States
| | - Erin Corriveau
- Department of Family Medicine, University of Kansas Medical Center, Kansas City, KS, United States
- Unified Government of Wyandotte County Health Department, Kansas City, KS, United States
| | - Allen Greiner
- Department of Family Medicine, University of Kansas Medical Center, Kansas City, KS, United States
- Unified Government of Wyandotte County Health Department, Kansas City, KS, United States
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Mabachi NM, Wexler C, Acharya H, Maloba M, Oyowe K, Goggin K, Finocchario-Kessler S. Piloting a systems level intervention to improve cervical cancer screening, treatment and follow up in Kenya. Front Med (Lausanne) 2022; 9:930462. [PMID: 36186820 PMCID: PMC9520305 DOI: 10.3389/fmed.2022.930462] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 08/16/2022] [Indexed: 11/13/2022] Open
Abstract
Although preventable, Cervical Cancer (CC) is the leading cause of cancer deaths among women in Sub-Saharan Africa with the highest incidence in East Africa. Kenyan guidelines recommend an immediate screen and treat approach using either Pap smear or visual screening methods. However, system (e.g., inadequate infrastructure, weak treatment, referral and tracking systems) and patient (e.g., stigma, limited accessibility, finance) barriers to comprehensive country wide screening continue to exist creating gaps in the pathways of care. These gaps result in low rates of eligible women being screened for CC and a high loss to follow up rate for treatment. The long-term goal of 70% CC screening and treatment coverage can partly be achieved by leveraging electronic health (eHealth, defined here as systems using Internet, computer, or mobile applications to support the provision of health services) to support service efficiency and client retention. To help address system level barriers to CC screening treatment and follow up, our team developed an eHealth tool—the Cancer Tracking System (CATSystem), to support CC screening, treatment, and on-site and external referrals for reproductive age women in Kenya. Preliminary data showed a higher proportion of women enrolled in the CATSystem receiving clinically adequate (patients tested positive were treated or rescreened to confirm negative within 3 months) follow up after a positive/suspicious screening, compared to women in the retrospective arm.
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Affiliation(s)
- Natabhona M. Mabachi
- Practice-Based Research, Innovation, and Evaluation Division, American Academy of Family Physicians, Leawood, KS, United States
- Department of Family and Community Medicine, University of Kansas Medical Center, Kansas City, KS, United States
- *Correspondence: Natabhona M. Mabachi,
| | - Catherine Wexler
- Department of Family and Community Medicine, University of Kansas Medical Center, Kansas City, KS, United States
| | - Harshdeep Acharya
- Department of Family and Community Medicine, University of Kansas Medical Center, Kansas City, KS, United States
| | - May Maloba
- Global Health Innovations, Nairobi, Kenya
| | | | - Kathy Goggin
- Children’s Mercy Research Institute, Kansas City, MO, United States
| | - Sarah Finocchario-Kessler
- Department of Family and Community Medicine, University of Kansas Medical Center, Kansas City, KS, United States
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Mokua S, Maloba M, Wexler C, Goggin K, Staggs V, Mabachi N, Maosa N, Babu S, Hurley E, Finocchario-Kessler S. Evaluating the efficacy of the HITSystem 2.1 to improve PMTCT retention and maternal viral suppression in Kenya: Study protocol of a cluster-randomized trial. PLoS One 2022; 17:e0263988. [PMID: 35881649 PMCID: PMC9321364 DOI: 10.1371/journal.pone.0263988] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Accepted: 01/28/2022] [Indexed: 11/19/2022] Open
Abstract
Background Gaps in the provision of guideline-adherent prevention of mother-to-child transmission of HIV (PMTCT) services and maternal retention in care contribute to nearly 8000 Kenyan infants becoming infected with HIV annually. Interventions that routinize evidence-based PMTCT service delivery and foster consistent patient engagement are essential to eliminating mother-to-child transmission of HIV. The HITSystem 2.1 is an eHealth intervention that aims to improve retention in PMTCT services and viral load monitoring, using electronic alerts to providers and SMS to patients. This study will evaluate the impact, implementation, and cost-effectiveness of HITSystem 2.1. Method This cluster randomized trial will be conducted at 12 study hospital (6 intervention, 6 control). Pregnant women living with HIV who have initiated PMTCT care ≤36 weeks gestation are eligible. Women enrolled at control hospitals will receive standard-of-care PMTCT services. Women enrolled at intervention hospitals will receive standard-of-care PMTCT services plus enhanced HITSystem 2.1 tracking. Mixed logistic regression models will compare the arms on two primary outcomes: (1) completed guideline-adherence PMTCT services and (2) viral suppression at both delivery and 6 months postpartum. We will assess associations between provider and patient characteristics (disclosure status, partner status, depression, partner support), PMTCT knowledge, and motivation with retention outcomes. Using the RE-AIM model, we will also assess implementation factors to guide sustainable scale-up. Finally, a cost-effectiveness analysis will be conducted. Discussion This study will provide insights regarding the development and adaptation of eHealth strategies to meet the global goal of eliminating new HIV infections in children and optimizing maternal health through PMTCT services. If efficacious, implementation and cost-effectiveness data gathered in this study will guide scale-up across Kenyan health facilities. Trial registration This study was registered at clinicaltrials.gov (NCT04571684) on October 1, 2020.
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Affiliation(s)
- Sharon Mokua
- Kenya Medical Research Institute, Nairobi, Kenya
- * E-mail: ,
| | - May Maloba
- Global Health Innovations–Kenya, Nairobi, Kenya
| | - Catherine Wexler
- Department of Family Medicine, University of Kansas Medical Center, Kansas City, Missouri, United States of America
| | - Kathy Goggin
- Children’s Mercy Kansas City, Health Services and Outcomes Research, Kansas City, Missouri, United States of America
- University of Missouri-Kansas City, School of Medicine, Kansas City, Missouri, United States of America
| | - Vincent Staggs
- Children’s Mercy Kansas City, Health Services and Outcomes Research, Kansas City, Missouri, United States of America
| | - Natabhona Mabachi
- Department of Family Medicine, University of Kansas Medical Center, Kansas City, Missouri, United States of America
| | | | | | - Emily Hurley
- Children’s Mercy Kansas City, Health Services and Outcomes Research, Kansas City, Missouri, United States of America
| | - Sarah Finocchario-Kessler
- Department of Family Medicine, University of Kansas Medical Center, Kansas City, Missouri, United States of America
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Khamadi S, Lwembe R, Maosa N, Maloba M, Wexler C, Sandbulte M, Goggin K, Babu S, Finocchario-Kessler S. HIV Drug Resistance in Kenyan Infants Diagnosed With HIV and Their Mothers. Pediatr Infect Dis J 2022; 41:312-314. [PMID: 34955520 DOI: 10.1097/inf.0000000000003436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The presence and type of HIV drug resistance mutations among 5 infants diagnosed with HIV were assessed and compared with their mothers' viral mutations. Mother and infant blood samples were sequenced and screened for HIV drug resistance mutations using the Stanford HIV Sequence Database. Three of 5 (60%) mother-infant pairs harbored HIV drug resistance mutations.
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Affiliation(s)
- Samoel Khamadi
- From the Kenya Medical Research Institute, Center for Virus Research, Nairobi, Kenya
| | - Raphael Lwembe
- From the Kenya Medical Research Institute, Center for Virus Research, Nairobi, Kenya
| | | | - May Maloba
- Global Health Innovations, Nairobi, Kenya
| | - Catherine Wexler
- Department of Family Medicine, University of Kansas Medical Center, Kansas City, Kansas
| | - Matthew Sandbulte
- Department of Family Medicine, University of Kansas Medical Center, Kansas City, Kansas
| | - Kathy Goggin
- Children's Mercy Kansas City, Health Services and Outcomes Research, Kansas City, Missouri
- University of Missouri-Kansas City, School of Medicine, Kansas City, Missouri
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Wexler C, Kamau Y, Muchoki E, Babu S, Maosa N, Maloba M, Brown M, Goggin K, Mabachi N, Gautney B, Finocchario-Kessler S. Implementing at-birth, point-of-care HIV testing in Kenya: a qualitative study using the Consolidated Framework for Implementation Research. Implement Sci Commun 2021; 2:89. [PMID: 34380567 PMCID: PMC8359118 DOI: 10.1186/s43058-021-00188-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 07/25/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND At-birth and point-of-care (POC) testing can expedite early infant diagnosis of HIV and improve infant outcomes. Guided by the Consolidated Framework for Implementation Research (CFIR), this study describes the implementation of an at-birth POC testing pilot from the perspective of implementing providers and identifies the factors that might support and hinder the scale up of these promising interventions. METHODS We conducted 28 focus group discussions (FGDs) with 48 providers across 4 study sites throughout the course of a pilot study assessing the feasibility and impact of at-birth POC testing. FGDs were audio-recorded, transcribed, and analyzed for a priori themes related to CFIR constructs. This qualitative study was nested within a larger study to pilot and evaluate at-birth and POC HIV testing. RESULTS Out of the 39 CFIR constructs, 30 were addressed in the FGDs. While all five domains were represented, major themes revolved around constructs related to intervention characteristics, inner setting, and outer setting. Regarding intervention characteristics, the advantages of at-birth POC (rapid turnaround time resulting in improved patient management and enhanced patient motivation) were significant enough to encourage provider uptake and enthusiasm. Challenges at the intervention level (machine breakdown, processing errors), inner settings (workload, limited leadership engagement, challenges with access to information), and outer setting (patient-level challenges, limited engagement with outer setting stakeholders) hindered implementation, frustrated providers, and resulted in missed opportunities for testing. Providers discussed how throughout the course of the study adaptations to implementation (improved channels of communication, modified implementation logistics) were made to overcome some of these challenges. To improve implementation, providers cited the need for enhanced training and for greater involvement among stakeholders outside of the implementing team (i.e., other clinicians, hospital administrators and implementing partners, county and national health officials). Despite provider enthusiasm for the intervention, providers felt that the lack of engagement from leadership within the hospital and in the outer setting would preclude sustained implementation outside of a research setting. CONCLUSION Despite demonstrated feasibility and enthusiasm among implementing providers, the lack of outer setting support makes sustained implementation of at-birth POC testing unlikely at this time. The findings highlight the multi-dimensional aspect of implementation and the need to consider facilitators and barriers within each of the five CFIR domains. TRIAL REGISTRATION ClinicalTrials.gov, NCT03435887 . Retrospectively registered on 19 February 2020.
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Affiliation(s)
- Catherine Wexler
- Department of Family Medicine, University of Kansas Medical Center, Kansas City, KS, USA.
| | - Yvonne Kamau
- Department of Family Medicine, University of Kansas Medical Center, Kansas City, KS, USA
| | | | | | | | - May Maloba
- Global Health Innovations - Kenya, Nairobi, Kenya
| | - Melinda Brown
- Department of Family Medicine, University of Kansas Medical Center, Kansas City, KS, USA
| | - Kathy Goggin
- Health Services and Outcomes Research, Children's Mercy Kansas City, Kansas City, MO, USA
- School of Medicine, University of Missouri-Kansas City, Kansas City, MO, USA
| | - Natabhona Mabachi
- Department of Family Medicine, University of Kansas Medical Center, Kansas City, KS, USA
| | - Brad Gautney
- Global Health Innovations - USA, Dallas, TX, USA
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Mabachi NM, Brown M, Wexler C, Goggin K, Maloba M, Olungae D, Gautney B, Finocchario-Kessler S. "Friendly reminder: hi! It is that time again ☺": understanding PMTCT care text message design preferences amongst pre- and post-partum women and their male partners. BMC Public Health 2021; 21:1491. [PMID: 34340672 PMCID: PMC8330020 DOI: 10.1186/s12889-021-11444-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 07/01/2021] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Prevention of mother-to-child HIV transmission (PMTCT) services in Kenya can be strengthened through the delivery of relevant and culturally appropriate SMS messages. METHODS This study reports on the results of focus groups conducted with pre and postnatal women living with HIV (5 groups, n = 40) and their male partners (3 groups, n = 33) to elicit feedback and develop messages to support HIV+ women's adherence to ART medication, ANC appointments and a facility-based birth. The principles of message design informed message development. RESULTS Respondents wanted ART adherence messages that were low in verbal immediacy (ambiguous), came from an anonymous source, and were customized in timing and frequency. Unlike other studies, low message immediacy was prioritized over customization of message content. For retention, participants preferred messages with high verbal immediacy-direct appointment reminders and references to the baby-sent infrequently from a clinical source. CONCLUSION Overall, participants favored content that was brief, cheerful, and emotionally appealing.
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Affiliation(s)
- Natabhona M Mabachi
- Department of Family Medicine, University of Kansas Medical Center, Mailstop 3064, 4125 Rainbow Blvd., Kansas City, KS, 66160, USA.
| | - Melinda Brown
- Department of Family Medicine, University of Kansas Medical Center, Mailstop 3064, 4125 Rainbow Blvd., Kansas City, KS, 66160, USA
| | - Catherine Wexler
- Department of Family Medicine, University of Kansas Medical Center, Mailstop 3064, 4125 Rainbow Blvd., Kansas City, KS, 66160, USA
| | - Kathy Goggin
- Children's Mercy Hospitals and Clinics, Health Services and Outcomes Research, Kansas City, MO, USA
| | - May Maloba
- Global Health Innovations (GHI), Nairobi, Kenya
| | - Dama Olungae
- Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
| | - Brad Gautney
- Global Health Innovations (GHI), Dallas, Texas, USA
| | - Sarah Finocchario-Kessler
- Department of Family Medicine, University of Kansas Medical Center, Mailstop 3064, 4125 Rainbow Blvd., Kansas City, KS, 66160, USA
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Finocchario-Kessler S, Wexler C, Brown M, Goggin K, Lwembe R, Nazir N, Gautney B, Khamadi S, Babu S, Muchoki E, Maosa N, Mabachi N, Kamau Y, Maloba M. Piloting the Feasibility and Preliminary Impact of Adding Birth HIV Polymerase Chain Reaction Testing to the Early Infant Diagnosis Guidelines in Kenya. Pediatr Infect Dis J 2021; 40:741-745. [PMID: 33990521 PMCID: PMC8274583 DOI: 10.1097/inf.0000000000003172] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/30/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND In Kenya, standard early infant diagnosis (EID) with polymerase chain reaction (PCR) testing at 6-week postnatal achieves early treatment initiation (<12 weeks) in <20% of HIV+ infants. Kenya's new early infant diagnosis guidelines tentatively proposed adding PCR testing at birth, pending results from pilot studies. METHODS We piloted birth testing at 4 Kenyan hospitals between November 2017 and November 2018. Eligible HIV-exposed infants were offered both point-of-care and PCR HIV testing at birth (window 0 to <4 weeks) and 6 weeks (window 4-12 weeks). We report the: proportion of infants tested at birth, 6-week, and both birth and 6-week testing; median infant age at results; seropositivity and antiretroviral therapy initiation. RESULTS Final sample included 624 mother-infant pairs. Mean maternal age was 30.4 years, 73.2% enrolled during antenatal care and 89.9% had hospital deliveries. Among the 590 mother-infants pairs enrolled before 4 weeks postnatal, 452 (76.6%) completed birth testing before 4 weeks, with 360 (79.6%) testing within 2 weeks, and 178 (39.4%) before hospital discharge (0-2 days). Mothers were notified of birth PCR results at a median infant age of 5.4 weeks. Among all 624 enrolled infants, 575 (92.1%) were tested during the 6-week window; 417 (66.8%) received testing at both birth and 6-weeks; and 207 received incomplete testing (93.3% only 1 PCR and 6.7% no PCR). Four infants were diagnosed with HIV, and 3 infants were initiated on antiretroviral therapy early, before 12 weeks of age. CONCLUSIONS Uptake of PCR testing at birth was high and a majority of infants received repeat testing at 6 weeks of age.
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Affiliation(s)
| | - Catherine Wexler
- From the Department of Family Medicine, University of Kansas Medical Center, Kansas City, Missouri
| | - Melinda Brown
- From the Department of Family Medicine, University of Kansas Medical Center, Kansas City, Missouri
| | - Kathy Goggin
- Children’s Mercy Kansas City, Health Services and Outcomes Research, Kansas City, Missouri
- School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri
| | - Raphael Lwembe
- Center for Virus Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Niaman Nazir
- Department of Preventive Medicine, University of Kansas Medical Center, Kansas City, Missouri
| | | | - Samoel Khamadi
- Center for Virus Research, Kenya Medical Research Institute, Nairobi, Kenya
| | | | | | | | - Natabhona Mabachi
- From the Department of Family Medicine, University of Kansas Medical Center, Kansas City, Missouri
| | - Yvonne Kamau
- From the Department of Family Medicine, University of Kansas Medical Center, Kansas City, Missouri
| | - May Maloba
- Global Health Innovations—Kenya, Nairobi, Kenya
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12
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Finocchario-Kessler S, Brown M, Maloba M, Nazir N, Wexler C, Goggin K, Dariotis JK, Mabachi N, Lagat S, Koech S, Gautney B. A Pilot Study to Evaluate the Impact of the HIV Infant Tracking System (HITSystem 2.0) on Priority Prevention of Mother-to-Child Transmission (PMTCT) Outcomes. AIDS Behav 2021; 25:2419-2429. [PMID: 33709212 PMCID: PMC8224224 DOI: 10.1007/s10461-021-03204-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/17/2021] [Indexed: 02/07/2023]
Abstract
We assessed the preliminary impact of the adapted HIV Infant Tracking System (HITSystem v2.0) intervention on prevention of mother-to-child transmission (PMTCT) outcomes using a matched cluster randomized design in two Kenyan government hospitals. Between November 2017 and June 2019, n = 157 pregnant women with HIV were enrolled and followed from their first PMTCT appointment until 12-weeks postpartum. Data from 135 women were analyzed (HITSystem 2.0: n = 53, standard of care (SOC): n = 82), excluding eight deaths, eight pregnancy losses, and six transfers/moves. The primary outcome, complete PMTCT retention, is an aggregate measure of attendance at all scheduled antenatal appointments, hospital-based delivery, and infant HIV-testing before 7-weeks postnatal. HITSystem 2.0 participants were more likely to receive complete PMTCT services compared to SOC (56.6% vs. 17.1% p < 0.001). In multivariate modeling, HITSystem 2.0 was the strongest predictor of complete PMTCT retention (aOR 5.7, [1.2-90.8], p = 0.032). SOC participants had 1.91 increased hazard rate of PMTCT disengagement; (aHR 6.8, [2.2-21.1]; p < 0.001).
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Affiliation(s)
- Sarah Finocchario-Kessler
- Department of Family Medicine, University of Kansas Medical Center, Mailstop 4010, 3901 Rainbow Boulevard, Kansas City, KS, 66160, USA.
| | - Melinda Brown
- Department of Family Medicine, University of Kansas Medical Center, Mailstop 4010, 3901 Rainbow Boulevard, Kansas City, KS, 66160, USA
| | - May Maloba
- Global Health Innovations, Nairobi, Kenya
| | - Niaman Nazir
- Department of Family Medicine, University of Kansas Medical Center, Mailstop 4010, 3901 Rainbow Boulevard, Kansas City, KS, 66160, USA
| | - Catherine Wexler
- Department of Family Medicine, University of Kansas Medical Center, Mailstop 4010, 3901 Rainbow Boulevard, Kansas City, KS, 66160, USA
| | - Kathy Goggin
- Health Services and Outcomes Research, Children's Mercy, Kansas City, MO, USA
- Schools of Medicine and Pharmacy, University of Missouri-Kansas City, Kansas City, MO, USA
| | - Jacinda K Dariotis
- Department of Human Development and Family Studies & Family Resiliency Center, University of Illinois at Urbana-Champaign, Urbana, IL, USA
| | - Natabhona Mabachi
- Department of Family Medicine, University of Kansas Medical Center, Mailstop 4010, 3901 Rainbow Boulevard, Kansas City, KS, 66160, USA
| | | | - Sharon Koech
- Global Health Innovations, Nairobi, Kenya
- Ministry of Health, Nandi County, Kenya
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13
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Wexler C, Maloba M, Goggin K, Kale SB, Maosa N, Muchoki E, Brown M, Gautney B, Finocchario-Kessler S. ART Initiation for Infants Diagnosed With HIV Through Point of Care and Conventional Polymerase Chain Reaction Testing in Kenya: A Case Series. Pediatr Infect Dis J 2021; 40:e151-e153. [PMID: 33464012 PMCID: PMC7954882 DOI: 10.1097/inf.0000000000003032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
We sought to understand the sequence of testing and treatment among nine infants offered both conventional and point-of-care testing and diagnosed as HIV-positive by 6 months of age in Kenya. One infant received per protocol testing and treatment. Patient-level (late presentation and disengagement), provider-level (reluctance and error/oversight) and system-level (stock outs, errors) challenges delayed diagnosis and treatment. Early point-of-care testing can streamline testing; however, challenges mitigate benefits.
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Affiliation(s)
- Catherine Wexler
- Department of Family Medicine, University of Kansas Medical Center, Kansas City, KS
| | - May Maloba
- Global Health Innovations, Nairobi, Kenya
| | - Kathy Goggin
- Health Services and Outcomes Research, Children’s Mercy Kansas City, Kansas City, MO
- School of Medicine, University of Missouri-Kansas City, Kansas City, MO
| | | | | | | | - Melinda Brown
- Department of Family Medicine, University of Kansas Medical Center, Kansas City, KS
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14
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Wexler C, Nazir N, Gautney B, Maloba M, Brown M, Goggin K, Lwembe R, Finocchario-Kessler S. Predictors of Early ART Initiation Among HIV + Infants in Kenya: A Retrospective Review of HITSystem Data from 2013 to 2017. Matern Child Health J 2021; 24:739-747. [PMID: 32285335 DOI: 10.1007/s10995-020-02909-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Early initiation of antiretroviral therapy (ART, before 12 weeks of age) among infants living with HIV reduces infant mortality and slows disease progression. However, inefficiencies in early infant diagnosis processes prevents timely ART initiation among infants living with HIV in Kenya. This study assesses predictors of early ART initiation among infants living with HIV in Kenya. DESIGN We retrospectively reviewed data from 96 infants living with HIV born between January 2013 and June 2017 at 6 Kenyan government hospitals. METHODS The primary outcome was infant receipt of ART by 12 weeks of age. We assessed bivariable and multivariable predictors of ART initiation by 12 weeks of age. RESULTS Among 96 infants living with HIV, 82 (85.4%) infants initiated ART at a median infant age of 17.1 weeks. Of the 82 infants who started ART, only 17 (20.7%) initiated ART by 12 weeks of age. In multivariable logistic regression analyses, testing per national guidelines (< 7 weeks of age) (aOR 40.14 [3.96-406.97], p = 0.002), shorter turnaround time for result notification (≤ 4 weeks) (aOR 11.30 [2.02-63.34], p = 0.006), and ART initiation within 3 days of mother notification (aOR 7.32 [1.41-38.03], p = 0.006) were significantly associated with ART initiation by 12 weeks of age. CONCLUSION Current implementation of early infant diagnosis services in Kenyan only achieves targets for early ART initiation in one-fifth of infants with HIV. Strengthening services to support earlier infant testing and streamlined processes for early infant diagnosis may increase the proportion of infants who receive timely ART.
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Affiliation(s)
- Catherine Wexler
- Department of Family Medicine, University of Kansas Medical Center, 3901 Rainbow Blvd., Kansas City, KS, 66160, USA.
| | - Niaman Nazir
- Department of Preventive Medicine and Public Health, University of Kansas Medical Center, Kansas City, KS, USA
| | | | - May Maloba
- Global Health Innovations, Nairobi, Kenya
| | - Melinda Brown
- Department of Family Medicine, University of Kansas Medical Center, 3901 Rainbow Blvd., Kansas City, KS, 66160, USA
| | - Kathy Goggin
- Health Services and Outcomes Research, Children's Mercy Kansas City, Kansas City, MO, USA.,University of Missouri- Kansas City School of Medicine, Kansas City, MO, USA
| | - Raphael Lwembe
- Center for Virus Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Sarah Finocchario-Kessler
- Department of Family Medicine, University of Kansas Medical Center, 3901 Rainbow Blvd., Kansas City, KS, 66160, USA
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15
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Wexler C, Brown M, Maloba M, Goggin K, Mabachi N, Kamau Y, Gautney B, Koech S, Lagat S, Finocchario-Kessler S. Women's preferences, expectations, and experiences with male partner support throughout prevention of mother to child transmission of HIV services: a mixed-methods study. AIDS Care 2020; 33:1059-1067. [PMID: 33300370 DOI: 10.1080/09540121.2020.1859444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Male involvement in prevention of mother to child transmission of HIV (PMTCT) care improves maternal and child outcomes. We conducted a mixed-methods study at two Kenyan government hospitals. We quantitatively assessed women's expectations and preferences for male partner involvement in PMTCT and male partner attendance at PMTCT appointments. Qualitative interviews with women during the postpartum period assessed types of support women received from their male partners. At enrollment, most participants wanted (75%) and expected (69%) male partners to attend appointments; yet, only 9% had a male partner attend any appointments. Most women agreed that their partner would: support them financially (81%), help follow doctor's guidance (61%), support a hospital-based delivery (85%), and want to receive text messages (68%). Expectations and preferences varied by women's characteristics, most notably experiences with mistreatment, disclosure status, and knowledge of male partner's HIV status. In qualitative interviews, instrumental (financial) support was the most frequently discussed type of support. Male partners also provided informational support by reminding women of medication or appointments. Women reported a variety of ways in which their male partners supported them through PMTCT; however, there was a gap between women's expectation for male partner attendance and the level of male attendance achieved.
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Affiliation(s)
- Catherine Wexler
- Department of Family Medicine, University of Kansas Medical Center, Kansas City, KS, USA
| | - Melinda Brown
- Department of Family Medicine, University of Kansas Medical Center, Kansas City, KS, USA
| | - May Maloba
- Global Health Innovations, Nairobi, Kenya
| | - Kathy Goggin
- Health Services and Outcomes Research, Children's Mercy Kansas City, Kansas City, MO, USA.,School of Medicine, University of Missouri-Kansas City, Kansas City, MO, USA
| | - Natabhona Mabachi
- Department of Family Medicine, University of Kansas Medical Center, Kansas City, KS, USA
| | - Yvonne Kamau
- Department of Family Medicine, University of Kansas Medical Center, Kansas City, KS, USA
| | | | - Sharon Koech
- Kenya Medical Research Institute, Nairobi, Kenya
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16
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Macharia LW, Wexler C, Brown M, Maloba M, Pricilla RA, Mabachi NM, Muchoki E, Babu S, Ochieng M, Gautney B, Goggin K, Finocchario-Kessler S. Implementation planning for community-based point-of-care HIV testing for infants: Recommendations from community leaders in Kenya. PLoS One 2020; 15:e0240476. [PMID: 33057444 PMCID: PMC7561120 DOI: 10.1371/journal.pone.0240476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Accepted: 09/25/2020] [Indexed: 11/18/2022] Open
Abstract
Background Early infant diagnosis (EID) establishes the presence of HIV infection in HIV-exposed infants and children younger than 18 months of age. EID services are hospital-based, and thus fail to capture HIV-exposed infants who are not brought to the hospital for care. Point-of-care (POC) diagnostic systems deployed in the community could increase the proportion tested and linked to treatment, but little feasibility and acceptability data is available. Methods Semi-structured interviews (n = 74) were conducted by a Kenyan team with community members (Community Health Workers/Volunteers [CHW/CHV], Traditional Birth Attendants [TBAs], community leaders) and parents of HIV-exposed infants at four study sites in Kenya to elicit feedback on the acceptability and feasibility of community-based POC HIV testing. Results Participants described existing community health resources that could be leveraged to support integration of community-based POC HIV testing; however, the added demand placed on CHW/CHV could pose a challenge. Participants indicated that other potential barriers (concerns about confidentiality, disclosure, and HIV stigma) could be overcome with strong engagement from trusted community leaders and health providers, community sensitization, and strategic location and timing of testing. These steps were seen to improve acceptability and maximize the recognized benefits (rapid results, improved reach) of community-based testing. Conclusion Community members felt that with strategic planning and engagement, community-based POC HIV testing could be a feasible and acceptable strategy to overcome the existing barriers of hospital-based EID.
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Affiliation(s)
- Lynton W. Macharia
- Department of Family Medicine, University of Kansas Medical Center, Kansas City, KS, United States of America
| | - Catherine Wexler
- Department of Family Medicine, University of Kansas Medical Center, Kansas City, KS, United States of America
| | - Melinda Brown
- Department of Family Medicine, University of Kansas Medical Center, Kansas City, KS, United States of America
| | - May Maloba
- Global Health Innovations, Nairobi, Kenya
| | | | - Natabhona M. Mabachi
- Department of Family Medicine, University of Kansas Medical Center, Kansas City, KS, United States of America
| | | | | | | | - Brad Gautney
- Global Health Innovations, Dallas, TX, United States of America
| | - Kathy Goggin
- Health Services and Outcomes Research, Children’s Mercy Hospitals and Clinics, Kansas City, MO, United States of America
- Schools of Medicine and Pharmacy, University of Missouri-Kansas City, Kansas City, MO, United States of America
| | - Sarah Finocchario-Kessler
- Department of Family Medicine, University of Kansas Medical Center, Kansas City, KS, United States of America
- * E-mail:
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17
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Wexler C, Nazir N, Maloba M, Brown M, Goggin K, Gautney B, Maosa N, Babu S, Muchoki E, Mabachi N, Lwembe R, Finocchario-Kessler S. Programmatic evaluation of feasibility and efficiency of at birth and 6-week, point of care HIV testing in Kenyan infant. PLoS One 2020; 15:e0240621. [PMID: 33035274 PMCID: PMC7546458 DOI: 10.1371/journal.pone.0240621] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 09/29/2020] [Indexed: 12/18/2022] Open
Abstract
Background Testing infants at birth and with more efficient point of care (POC) HIV diagnostic can streamline EID and expedite infant ART initiation. We evaluated the implementation of at birth and 6-week POC testing to assess the effectiveness and feasibility when implemented by existing hospital staff in Kenya. Methods Four government hospitals were randomly assigned to receive a GeneXpert HIV-1 Qual (n = 2) or Alere m-PIMA (n = 2) machine for POC testing. All HIV-exposed infants enrolled were eligible to receive POC testing at birth and 6-weeks of age. The primary outcome was repeat POC testing, defined as testing both at birth and 6-weeks of age. Secondary outcomes included predictors of repeat POC testing, POC efficiency (turnaround times of key services), and operations (failed POC results, missed opportunities). Results Of 626 enrolled infants, 309 (49.4%) received repeat POC testing, 115 (18.4%) were lost to follow up after an at-birth test, 120 (19.2%) received POC testing at 6-weeks only, 80 (12.8%) received no POC testing, and 2 (0.3%) received delayed POC testing (>12 weeks of age). Three (0.4%) were identified as HIV-positive. Of the total 853 POC tests run at birth (n = 424) or 6-weeks (n = 429), 806 (94.5%) had a valid result documented and 792 (98.3%) results had documented maternal notification. Mean time from sample collection to notification was 1.08 days, with 751 (94.8%) notifications on the same day as sample collection. Machine error rates at birth and 6-weeks were 8.5% and 2.5%, respectively. A total of 198 infants presented for care (48 at birth; 150 at 6-weeks) without receiving a POC test, representing missed opportunities for testing. Discussion At birth POC testing can streamline infant HIV diagnosis, expedite ART initiation and can be implemented by existing hospital staff. However, maternal disengagement and missed opportunities for testing must be addressed to realize the full benefits of at birth POC testing.
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Affiliation(s)
- Catherine Wexler
- Department of Family Medicine, University of Kansas Medical Center, Kansas City, KS, United States of America
- * E-mail:
| | - Niaman Nazir
- Department of Preventive Medicine, University of Kansas Medical Center, Kansas City, KS, United States of America
| | - May Maloba
- Global Health Innovations–Kenya, Nairobi, Kenya
| | - Melinda Brown
- Department of Family Medicine, University of Kansas Medical Center, Kansas City, KS, United States of America
| | - Kathy Goggin
- Children’s Mercy Kansas City, Health Services and Outcomes Research, Kansas City, MO, United States of America
- School of Medicine, University of Missouri-Kansas City, Kansas City, MO, United States of America
| | - Brad Gautney
- Global Health Innovations, Dallas, TX, United States of America
| | | | | | | | - Natabhona Mabachi
- Department of Family Medicine, University of Kansas Medical Center, Kansas City, KS, United States of America
| | | | - Sarah Finocchario-Kessler
- Department of Family Medicine, University of Kansas Medical Center, Kansas City, KS, United States of America
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18
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Sandbulte M, Brown M, Wexler C, Maloba M, Gautney B, Goggin K, Muchoki E, Babu S, Maosa N, Finocchario-Kessler S. Maternal viral load monitoring: Coverage and clinical action at 4 Kenyan hospitals. PLoS One 2020; 15:e0232358. [PMID: 32469876 PMCID: PMC7259657 DOI: 10.1371/journal.pone.0232358] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Accepted: 04/13/2020] [Indexed: 12/13/2022] Open
Abstract
Background Kenya’s guidelines for prevention of mother-to-child transmission of HIV (PMTCT) recommend routine viral load (VL) monitoring for pregnant and breastfeeding women. Method We assessed PMTCT VL monitoring and clinical action occurring between last menstrual period (LMP) and 6 months postpartum at 4 Kenyan government hospitals. Pregnant women enrolled in the HIV Infant Tracking System from May 2016-March 2018 were included. We computed proportions who received VL testing within recommended timeframes and who received clinical action after unsuppressed VL result. Results Of 424 participants, any VL testing was documented for 305 (72%) women and repeat VL testing was documented for 79 (19%). Only 115 women (27%) received a guideline-adherent baseline VL test and 27 (6%) received a guideline-adherent baseline and repeat VL test sequence. Return of baseline and repeat VL test results to the facility was high (average 96%), but patient notification of VL results was low (36% baseline and 49% repeat). Clinical action for unsuppressed VL results was even lower: 11 of 38 (29%) unsuppressed baseline results and 2 of 14 (14%) unsuppressed repeat results triggered clinical action. Discussion Guideline-adherent VL testing and clinical intervention during PMTCT must be prioritized to improve maternal care and reduce the risk of HIV transmission to infants.
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Affiliation(s)
- Matthew Sandbulte
- Department of Family Medicine, University of Kansas Medical Center, Kansas City, KS, United States of America
| | - Melinda Brown
- Department of Family Medicine, University of Kansas Medical Center, Kansas City, KS, United States of America
| | - Catherine Wexler
- Department of Family Medicine, University of Kansas Medical Center, Kansas City, KS, United States of America
| | - May Maloba
- Global Health Innovations, Nairobi, Kenya
| | - Brad Gautney
- Global Health Innovations, Dallas, TX, United States of America
| | - Kathy Goggin
- Health Services and Outcomes Research, Children's Mercy Kansas City, Kansas City, MO, United States of America.,School of Medicine, University of Missouri-Kansas City, Kansas City, MO, United States of America
| | | | | | | | - Sarah Finocchario-Kessler
- Department of Family Medicine, University of Kansas Medical Center, Kansas City, KS, United States of America
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19
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Hurley EA, Odeny B, Wexler C, Brown M, MacKenzie A, Goggin K, Maloba M, Gautney B, Finocchario-Kessler S. "It was my obligation as mother": 18-Month completion of Early Infant Diagnosis as identity control for mothers living with HIV in Kenya. Soc Sci Med 2020; 250:112866. [PMID: 32145483 DOI: 10.1016/j.socscimed.2020.112866] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Revised: 12/31/2019] [Accepted: 02/16/2020] [Indexed: 12/26/2022]
Abstract
RATIONALE Early Infant Diagnosis (EID) is critical to timely identification of HIV and rapid treatment initiation for infants found to be infected. Completing the EID cascade involves a series of age-specific tests between birth and 18 months and can be challenging for mother- infant pairs in low-resource settings. Even prior to recent increases in Kenya's testing recommendations, approximately 22% of mother-infant pairs enrolled in EID were lost to follow-up. As EID cascades become increasingly complex, identifying strategies to maximize retention becomes even more essential. Despite ongoing health system improvements, we still lack a framework for understanding the individual-level, psychosocial processes underlying EID completion-insight that could be essential for shaping strategies to support patients and close gaps in retention. OBJECTIVE Our objective was to explain individual-level processes that lead to EID completion among mothers who successfully completed the EID cascade. METHODS Using qualitative methods informed by grounded theory, we conducted 65 interviews with Kenyan mothers who completed EID. RESULTS We identified three themes related to completion: (1) Negative motivation, from the consequences of infant infection, fear of postnatal transmission, and burden of maternal failure; (2) Positive motivation, from achieving a final goal, responding to provider support, and maximizing infant health; and (3) Overcoming challenges, through resolve/resiliency, planning/privatizing and rejecting stigma/leveraging support. CONCLUSION Overall, the EID cascade served as a framing process for women to secure an identity as a good mother. Successful EID completion was the product of a strong motivational foundation channeled into strategies to surmount persistent challenges. Participant accounts of overcoming challenges highlight their resiliency as well as the outstanding need to address financial, logistical, and social barriers to care. Future EID programs may capitalize on these findings by affirming patients' quest for identity control, leveraging positive motivators, and expanding peer support structures to help mothers feel connected throughout the cascade.
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Affiliation(s)
- Emily A Hurley
- Children's Mercy Kansas City, Health Services and Outcomes Research, Kansas City, MO, USA.
| | - Beryne Odeny
- University of Washington School of Public Health, Department of Global Health, Seattle, WA, USA
| | - Catherine Wexler
- University of Kansas Medical Center, Department of Family Medicine, Kansas City, KS, USA
| | - Melinda Brown
- University of Kansas Medical Center, Department of Family Medicine, Kansas City, KS, USA
| | - Alexander MacKenzie
- Children's Mercy Kansas City, Health Services and Outcomes Research, Kansas City, MO, USA
| | - Kathy Goggin
- Children's Mercy Kansas City, Health Services and Outcomes Research, Kansas City, MO, USA; University of Missouri-Kansas City, School of Medicine, Kansas City, MO, USA; University of Missouri-Kansas City, School of Pharmacy, Kansas City, MO, USA
| | - May Maloba
- Global Health Innovations, Nairobi, Kenya
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20
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Mabachi NM, Brown M, Sandbulte M, Wexler C, Goggin K, Maloba M, Finocchario-Kessler S. Using a Social Support Framework to Understand How HIV Positive Kenyan Men Engage in PMTCT/EID Care: Qualitative Insights From Male Partners. AIDS Behav 2020; 24:18-28. [PMID: 30877581 PMCID: PMC6745277 DOI: 10.1007/s10461-019-02451-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Greater male partner involvement in Prevention of Mother to Child Transmission (PMTCT) and Early Infant Diagnosis (EID) is associated with improved outcomes. Perceived low social support for the mother can negatively impact the uptake of PMTCT/EID services. Most research relies on women's reports of the types and quality of male partner support received versus what is desired. This qualitative study examines Kenyan male partners' reported social support provision pre- and post-partum from their own perspective. The study was embedded within intervention development studies in Kenya designed to develop and pilot a PMTCT module of a web based system to improve EID. Focus groups were conducted with male partners of pregnant women with HIV and elicited feedback on male partner involvement in maternal and child care and factors affecting participation. Interviews were analyzed within a theoretical social support framework. Participants described providing tangible support (financial resources), informational support (appointment reminders) and emotional support (stress alleviation in the face of HIV-related adversity). African conceptualizations of masculinity and gender norms influenced the types of support provided. Challenges included economic hardship; insufficient social support from providers, peers and bosses; and HIV stigma. Collaboration among providers, mothers and partners; a community-based social support system; and recasting notions of traditional masculinity were identified as ways to foster male partner support.
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Affiliation(s)
- Natabhona M Mabachi
- Department of Family Medicine, University of Kansas Medical Center, Mailstop 3064, 4125 Rainbow Blvd., Kansas City, KS, 66160, USA.
| | - Melinda Brown
- Department of Family Medicine, University of Kansas Medical Center, Mailstop 3064, 4125 Rainbow Blvd., Kansas City, KS, 66160, USA
| | - Matthew Sandbulte
- Department of Family Medicine, University of Kansas Medical Center, Mailstop 3064, 4125 Rainbow Blvd., Kansas City, KS, 66160, USA
| | - Catherine Wexler
- Department of Family Medicine, University of Kansas Medical Center, Mailstop 3064, 4125 Rainbow Blvd., Kansas City, KS, 66160, USA
| | - Kathy Goggin
- Children's Mercy Kansas City, Health Services and Outcomes Research, Kansas City, MO, USA
| | - May Maloba
- Global Health Innovations, Nairobi, Kenya
| | - Sarah Finocchario-Kessler
- Department of Family Medicine, University of Kansas Medical Center, Mailstop 3064, 4125 Rainbow Blvd., Kansas City, KS, 66160, USA
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Wexler C, Maloba M, Brown M, Mabachi N, Goggin K, Gautney B, Odeny B, Finocchario-Kessler S. Factors affecting acceptance of at-birth point of care HIV testing among providers and parents in Kenya: A qualitative study. PLoS One 2019; 14:e0225642. [PMID: 31756242 PMCID: PMC6874324 DOI: 10.1371/journal.pone.0225642] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Accepted: 11/09/2019] [Indexed: 01/01/2023] Open
Abstract
Background At-birth and point-of-care (POC) HIV testing are emerging strategies to streamline infant HIV diagnosis and expedite ART initiation for HIV-positive infants. The purpose of this qualitative study was to evaluate factors influencing the provision and acceptance of at-birth POC testing among both HIV care providers and parents of HIV-exposed infants in Kenya. Methods We conducted semi-structured interviews with 26 HIV care providers and 35 parents of HIV-exposed infants (including 23 mothers, 6 fathers, and 3 mother-father pairs) at four study hospitals prior to POC implementation. An overview of best available evidence related to POC was presented to participants prior to each interview. Interviews probed about standard EID services, perceived benefits and risk of at-birth and POC testing, and suggested logistics of providing at-birth and POC. Interviews were audio recorded, translated (if necessary), and transcribed verbatim. Using the Transdisciplinary Model of Evidence Based Practice to guide analysis, transcripts were coded based on a priori themes related to environmental context, patient characteristics, and resources. Results Most providers (24/26) and parents (30/35) held favorable attitudes towards at-birth POC testing. The potential for earlier results to improve infant care and reduce parental anxiety drove preferences for at-birth POC testing. Parents with unfavorable views towards at-birth POC testing preferred standard testing at 6 weeks so that mothers could heal after birth and have time to bond with their newborn before–possibly–learning that their child was HIV-positive. Providers identified lack of resources (shortage of staff, expertise, and space) as a barrier. Discussion While overall acceptability of at-birth POC testing among HIV care providers and parents of HIV-exposed infants may facilitate uptake, barriers remain. Applying a task-shifting approach to implementation and ensuring providers receive training on at-birth POC testing may mitigate provider-related challenges. Comprehensive counseling throughout the antenatal and postpartum periods may mitigate patient-related challenges.
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Affiliation(s)
- Catherine Wexler
- Department of Family Medicine, University of Kansas Medical Center, Kansas City, Kansas, United States of America
- * E-mail:
| | - May Maloba
- Global Health Innovations, Nairobi, Kenya
| | - Melinda Brown
- Department of Family Medicine, University of Kansas Medical Center, Kansas City, Kansas, United States of America
| | - Natabhona Mabachi
- Department of Family Medicine, University of Kansas Medical Center, Kansas City, Kansas, United States of America
| | - Kathy Goggin
- Health Services and Outcomes Research, Children’s Mercy Kansas City, Kansas City, MO, United States of America
- School of Medicine, University of Missouri-Kansas City, Kansas City, MO, United States of America
| | - Brad Gautney
- Global Health Innovations, Dallas, TX, United States of America
| | - Beryne Odeny
- Department of Family Medicine, University of Kansas Medical Center, Kansas City, Kansas, United States of America
| | - Sarah Finocchario-Kessler
- Department of Family Medicine, University of Kansas Medical Center, Kansas City, Kansas, United States of America
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Brown M, Wexler C, Gautney B, Goggin K, Hurley EA, Odeny B, Maloba M, Lwembe R, Sandbulte M, Finocchario-Kessler S. eHealth Interventions for Early Infant Diagnosis: Mothers' Satisfaction with the HIV Infant Tracking System in Kenya. AIDS Behav 2019; 23:3093-3102. [PMID: 31313093 DOI: 10.1007/s10461-019-02579-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The HIV Infant Tracking System (HITSystem) is an eHealth intervention to improve early infant diagnosis (EID) through alerts to providers and text messages to mothers. This study explored mothers' experiences receiving standard and HITSystem-enhanced EID services to assess perceived intervention benefits, acceptability, and opportunities for improvement. This qualitative study was embedded within a cluster-randomized control trial to evaluate the HITSystem at six Kenyan government hospitals (3 intervention, 3 control). We conducted semi-structured interviews with 137 mothers attending EID follow-up visits. Compared to control sites, participants at HITSystem sites described enhanced EID quality; HITSystem-generated texts informed them of result availability and retesting needs, provided cues-to-action for clinic attendance, and engendered opportunities for patient support. They described improved EID efficiency through shorter waiting periods for results and fewer hospital visits. Participants reported high satisfaction with EID and acceptability of text messages; however, modifications to ensure text delivery, increase repeat testing reminders, include low literacy content options, and provide encouraging messages were suggested. These user experience data suggest improvements in EID at HITSystem sites when compared with control sites.
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Affiliation(s)
- Melinda Brown
- Department of Family Medicine, University of Kansas Medical Center, 3901 Rainbow Blvd., Kansas City, KS, 66160, USA.
| | - Catherine Wexler
- Department of Family Medicine, University of Kansas Medical Center, 3901 Rainbow Blvd., Kansas City, KS, 66160, USA
| | | | - Kathy Goggin
- Health Services and Outcomes Research, Children's Mercy Kansas City, Kansas City, MO, USA
- Schools of Medicine and Pharmacy, University of Missouri-Kansas City, Kansas City, MO, USA
| | - Emily A Hurley
- Health Services and Outcomes Research, Children's Mercy Kansas City, Kansas City, MO, USA
| | - Beryne Odeny
- Department of Family Medicine, University of Kansas Medical Center, 3901 Rainbow Blvd., Kansas City, KS, 66160, USA
- Global Health Innovations, Dallas, TX, USA
| | - May Maloba
- Global Health Innovations, Nairobi, Kenya
| | - Raphael Lwembe
- Centre for Virus Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Matthew Sandbulte
- Department of Family Medicine, University of Kansas Medical Center, 3901 Rainbow Blvd., Kansas City, KS, 66160, USA
| | - Sarah Finocchario-Kessler
- Department of Family Medicine, University of Kansas Medical Center, 3901 Rainbow Blvd., Kansas City, KS, 66160, USA
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Goggin K, Hurley EA, Staggs VS, Wexler C, Nazir N, Gautney B, Khamadi SA, Maloba M, Lwembe R, Finocchario-Kessler S. Rates and Predictors of HIV-Exposed Infants Lost to Follow-Up During Early Infant Diagnosis Services in Kenya. AIDS Patient Care STDS 2019; 33:346-353. [PMID: 31369296 DOI: 10.1089/apc.2019.0050] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Early infant diagnosis (EID) involves age-specific tracking and testing of HIV-exposed infants during the first 18 months of life and rapid initiation of life-saving treatment for those infected. In Kenya, pre-2013 data estimate EID lost to follow-up (LTFU) at 39-65%, yet no study has documented LTFU rates and predictors throughout the EID cascade since Option B+ fundamentally changed services by placing all HIV-positive expectant mothers on lifelong treatment. Using an explanatory mixed-method design, we assessed LTFU rates and predictors among 870 mother-infant dyads enrolled in EID in six urban/peri-urban Kenyan government hospitals. Mothers completed baseline surveys, and dyads were tracked through EID. We selected 12 baseline variables and modeled odds of LTFU at 9 and 18 months using mixed logistic regression. Qualitative interviews were conducted with 61 mothers to assess barriers and facilitators to completing EID. Thematically coded transcripts were used to interpret quantitative predictors of LTFU. By the 18-month test, 145 dyads (22%) were LTFU, with three-quarters of LTFU occurring between 9- and 18-month tests. Odds of LTFU at 18 months decreased by 10% for each additional year of maternal age and by 66% with HIV status disclosure. Qualitative data revealed how disclosure facilitated essential social support for EID completion and how older mothers attributed maturity and life experience to successful engagement in care. Findings suggest LTFU rates in Kenya have declined, but gaps remain in ensuring universal coverage. Efforts to improve retention should focus on increasing support for younger mothers and those who have not disclosed their HIV status.
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Affiliation(s)
- Kathy Goggin
- Division of Health Services and Outcomes Research, Children's Mercy Kansas City, Kansas City, Missouri
- School of Medicine and University of Missouri-Kansas City, Kansas City, Missouri
- School of Pharmacy, University of Missouri-Kansas City, Kansas City, Missouri
| | - Emily A. Hurley
- Division of Health Services and Outcomes Research, Children's Mercy Kansas City, Kansas City, Missouri
| | - Vincent S. Staggs
- Division of Health Services and Outcomes Research, Children's Mercy Kansas City, Kansas City, Missouri
- School of Medicine and University of Missouri-Kansas City, Kansas City, Missouri
- Biostatistics and Epidemiology Core, Children's Mercy Kansas City, Kansas City, Missouri
| | - Catherine Wexler
- Department of Family Medicine and University of Kansas Medical Center, Kansas City, Missouri
| | - Niaman Nazir
- Department of Preventive Medicine, University of Kansas Medical Center, Kansas City, Missouri
| | | | | | - May Maloba
- Global Health Innovations, Dallas, Texas
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Finocchario-Kessler S, Maloba M, Brown M, Gautney B, Goggin K, Wexler C, Mabachi N, Odeny B, Lagat S, Koech S, Dariotis JK, Odeny TA. Adapting the HIV Infant Tracking System to Support Prevention of Mother-to-Child Transmission of HIV in Kenya: Protocol for an Intervention Development Pilot Study in Two Hospitals. JMIR Res Protoc 2019; 8:e13268. [PMID: 31199305 PMCID: PMC6592400 DOI: 10.2196/13268] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Revised: 04/16/2019] [Accepted: 04/16/2019] [Indexed: 01/10/2023] Open
Abstract
Background Despite progress to expand access to HIV testing and treatment during pregnancy in Kenya, gaps still remain in prevention of mother-to-child transmission of HIV (PMTCT) services. This study addresses the need for effective and scalable interventions to support women throughout the continuum of care for PMTCT services in low-resource settings. Our research team has successfully implemented the HIV Infant Tracking System (HITSystem), a Web-based, system-level intervention to improve early infant diagnosis (EID) outcomes. Objective This study will expand the scope of the HITSystem to address PMTCT services to bridge the gap between maternal and pediatric HIV services and improve outcomes. This paper describes the intervention development protocol to adapt and pilot an HITSystem version 2.0 to assess acceptability, feasibility, and preliminary PMTCT outcomes in Kenya. Methods This is a 3-year intervention development study to adapt the current HITSystem intervention to support a range of PMTCT outcomes including appointment attendance, antiretroviral therapy (ART) adherence, hospital deliveries, and integration of maternal and pediatric HIV services in low-resource settings. The study will be conducted in 3 phases. Phase 1 will elicit feedback from intervention users (patients and providers) to guide development and refinement of the new PMTCT components and inform optimal implementation. In Phase 2, we will design and develop the HITSystem 2.0 features to support key PMTCT outcomes guided by clinical content experts and findings from Phase 1. Phase 3 will assess complete PMTCT retention (before, during, and after delivery) using a matched randomized pilot study design in 2 hospitals over 18 months. A total of N=108 HIV-positive pregnant women (n=54 per site) will be enrolled and followed from their first PMTCT appointment until infant HIV DNA Polymerase Chain Reaction testing at the target age of 6 weeks (<7 weeks) postnatal. Results Funding for this study was received in August 2015, enrollment in Phase 1 began in March 2016, and completion of data collection is expected by May 2019. Conclusions This protocol will extend, adapt, and pilot an HITSystem 2.0 version to improve attendance of PMTCT appointments, increase ART adherence and hospital-based deliveries, and prompt EID by 6 weeks postnatal. The HITSystem 2.0 aims to improve the integration of maternal and pediatric HIV services. Trial Registration ClinicalTrials.gov NCT02726607; https://clinicaltrials.gov/ct2/show/NCT02726607 (Archived by WebCite at http://www.webcitation.org/78VraLrOb) International Registered Report Identifier (IRRID) DERR1-10.2196/13268
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Affiliation(s)
| | - May Maloba
- Global Health Innovations, Nairobi, Kenya
| | - Melinda Brown
- Department of Family Medicine, University of Kansas Medical Center, Kansas City, KS, United States
| | - Brad Gautney
- Global Health Innovations, Dallas, TX, United States
| | - Kathy Goggin
- School of Medicine, University of Missouri-Kansas City, Kansas City, MO, United States.,Health Services and Outcomes Research, Children's Mercy Kansas City, Kansas City, MO, United States.,School of Pharmacy, University of Missouri-Kansas City, Kansas City, MO, United States
| | - Catherine Wexler
- Department of Family Medicine, University of Kansas Medical Center, Kansas City, KS, United States
| | - Natabhona Mabachi
- Department of Family Medicine, University of Kansas Medical Center, Kansas City, KS, United States
| | - Beryne Odeny
- Department of Family Medicine, University of Kansas Medical Center, Kansas City, KS, United States
| | - Silas Lagat
- Ministry of Health, Nandi County, Kapsabet, Kenya
| | - Sharon Koech
- Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Jacinda K Dariotis
- College of Education, Criminal Justice & Human Services, University of Cincinnati, Cincinnati, OH, United States
| | - Thomas A Odeny
- School of Medicine, University of Missouri-Kansas City, Kansas City, MO, United States.,Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
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Wexler C, Kamau Y, Halder R, Brown M, Maloba M, Mabachi N, Sandbulte M, Gautney B, Goggin K, Odeny T, Finocchario-Kessler S. "Closing the Gap": Provider Recommendations for Implementing Birth Point of Care HIV Testing. AIDS Behav 2019; 23:1073-1083. [PMID: 30542834 DOI: 10.1007/s10461-018-2363-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Delays in traditional HIV DNA PCR testing for early infant diagnosis (EID) at 6 weeks of age result in late antiretroviral treatment (ART). Birth point of care (POC) testing is an emerging strategy with the potential to streamline EID services. We elicited providers' recommendations for introducing birth POC testing to guide strategies in Kenya and similar settings. We conducted formative interviews with 26 EID providers from four Kenyan hospitals prior to POC implementation. Providers discussed the need for comprehensive training, covering both EID and POC-specific topics for all key personnel. Providers highlighted equipment considerations, such as protocols for maintenance and safe storage. Providers emphasized the need for maternal counseling to ensure patient acceptance and most agreed that specimen collection for birth POC testing should occur in the maternity department and supported a multidisciplinary approach. Though most providers supported ART initiation based on a positive birth POC result, a few expressed concerns with result validity. To maximize implementation success, provider training, equipment security, maternal counseling, and logistics of testing must be planned and communicated to providers.
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26
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Sandbulte MR, Gautney BJ, Maloba M, Wexler C, Brown M, Mabachi N, Goggin K, Lwembe R, Nazir N, Odeny TA, Finocchario-Kessler S. Infant HIV testing at birth using point-of-care and conventional HIV DNA PCR: an implementation feasibility pilot study in Kenya. Pilot Feasibility Stud 2019; 5:18. [PMID: 30701079 PMCID: PMC6347792 DOI: 10.1186/s40814-019-0402-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Accepted: 01/11/2019] [Indexed: 12/03/2022] Open
Abstract
Background Infant HIV diagnosis by HIV DNA polymerase chain reaction (PCR) testing at the standard 6 weeks of age is often late to mitigate the mortality peak that occurs in HIV positive infants’ first 2–3 months of life. Kenya recently revised their early infant diagnosis (EID) guidelines to include HIV DNA PCR testing at birth (pilot only), 6 weeks, 6 months, and 12 months postnatal and a final 18-month antibody test. The World Health Organization (WHO) approved point-of-care (POC) diagnostic platforms for infant HIV testing in resource-limited countries that could simplify logistics and expedite infant diagnosis. Sustainable scale-up and optimal utility in Kenya and other high-prevalence countries depend on robust implementation studies in diverse clinical settings. Methods We will pilot the implementation of birth testing by HIV DNA PCR, as well as two POC testing systems (Xpert HIV-1 Qual [Xpert] and Alere q HIV-1/2 Detect [Alere q]), on specimens collected from Kenyan infants at birth (0 to 2 weeks) and 6 weeks (4 to < 24 weeks) postnatal. The formative phase will inform optimal implementation of birth testing and two POC testing technologies. Qualitative interviews with stakeholders (providers, parents of HIV-exposed infants, and community members) will assess attitudes, barriers, and recommendations to optimize implementation at their respective sites. A non-blinded pilot study at four Kenyan hospitals (n = 2 Xpert, n = 2 Alere q platforms) will evaluate infant HIV POC testing compared with standard of care HIV DNA PCR testing in both the birth and 6-week windows. Objectives of the pilot are to assess uptake, efficiency, quality, implementation variables, user experiences of birth testing with both POC testing systems or with HIV DNA PCR, and costs. Discussion This study will generate data on the clinical impact and feasibility of adding HIV testing at birth utilizing POC and traditional PCR HIV testing strategies in resource-limited settings. Data from this pilot will inform the optimal implementation of Kenya’s birth testing guidelines and of POC testing systems for the improvement of EID outcomes. Trial registration ClinicalTrials.gov, NCT03435887. Registered 26 February 2018. Electronic supplementary material The online version of this article (10.1186/s40814-019-0402-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Matthew R Sandbulte
- 1Department of Family Medicine, University of Kansas Medical Center, Kansas City, KS USA
| | | | - May Maloba
- Global Health Innovations, Nairobi, Kenya
| | - Catherine Wexler
- 1Department of Family Medicine, University of Kansas Medical Center, Kansas City, KS USA
| | - Melinda Brown
- 1Department of Family Medicine, University of Kansas Medical Center, Kansas City, KS USA
| | - Natabhona Mabachi
- 1Department of Family Medicine, University of Kansas Medical Center, Kansas City, KS USA
| | - Kathy Goggin
- 4Health Services and Outcomes Research, Children's Mercy Hospitals and Clinics, Kansas City, MO USA.,5University of Missouri-Kansas City School of Medicine, Kansas City, MO USA
| | - Raphael Lwembe
- 6Centre for Virus Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Niaman Nazir
- 7Department of Preventive Medicine and Public Health, University of Kansas Medical Center, Kansas City, KS USA
| | - Thomas A Odeny
- 5University of Missouri-Kansas City School of Medicine, Kansas City, MO USA.,8Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
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Finocchario-Kessler S, Gautney B, Cheng A, Wexler C, Maloba M, Nazir N, Khamadi S, Lwembe R, Brown M, Odeny TA, Dariotis JK, Sandbulte M, Mabachi N, Goggin K. Evaluation of the HIV Infant Tracking System (HITSystem) to optimise quality and efficiency of early infant diagnosis: a cluster-randomised trial in Kenya. Lancet HIV 2018; 5:e696-e705. [PMID: 30309787 PMCID: PMC6289743 DOI: 10.1016/s2352-3018(18)30245-5] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Revised: 08/17/2018] [Accepted: 08/31/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND The HIV Infant Tracking System (HITSystem) is a web-based intervention linking providers of early infant diagnosis, laboratory technicians, and mothers and infants to improve outcomes for HIV-exposed infants. We aimed to evaluate the efficacy of the HITSystem on key outcomes of early infant diagnosis. METHODS We did a cluster-randomised trial at six hospitals in Kenya, which were matched on geographic region, resource level, and volume of patients (high, medium, and low). We randomly allocated hospitals within a matched pair to either the HITSystem (intervention; n=3) or standard of care (control; n=3). A random number generator was used to assign clusters. Investigators were unaware of the randomisation process. Eligible participants were mothers aged 18 years or older with an infant younger than 24 weeks presenting for their first early infant diagnosis appointment. The primary outcome was complete early infant diagnosis retention, which was defined as receipt of all indicated age-specific interventions until 18 months post partum (for HIV-negative infants) or antiretroviral therapy initiation (for HIV-positive infants). Analysis was per protocol in all randomised pairs judged eligible, excluding infant deaths and those who moved or were transferred to another health facility. Modified intention-to-treat sensitivity analyses judged all infant deaths and transfers as incomplete early infant diagnosis retention. Separate multivariable logistic regression analyses were done with intervention group, hospital volume, and significant covariates as fixed effects. This trial is registered with ClinicalTrials.gov, number NCT02072603; the trial has been completed. FINDINGS Between Feb 16, 2014, and Dec 31, 2015, 895 mother-infant pairs were enrolled. Of these, 87 were judged ineligible for analysis, 26 infants died, and 92 pairs moved or were transferred to another health facility. Thus, data from 690 mother-infant pairs were analysed, of whom 392 were allocated to the HITSystem and 298 to standard of care. Mother-infant pairs were followed up to Sept 30, 2017. Infants diagnosed as HIV-positive were followed up for a median of 2·1 months (IQR 1·6-4·8) and HIV-negative infants were followed up for a median of 17·0 months (IQR 16·6-17·6). Infants enrolled in the HITSystem were significantly more likely to receive complete early infant diagnosis services compared with those assigned standard of care (334 of 392 [85%] vs 180 of 298 [60%]; adjusted odds ratio [OR] 3·7, 95% CI 2·5-5·5; p<0·0001). No intervention effect was recorded at high-volume hospitals, but strong effects were seen at medium-volume and low-volume hospitals. Modified intention-to-treat analyses for complete early infant diagnosis were also significant (334 of 474 [70%] vs 180 of 334 [54%]; adjusted OR 2·0, 95% CI 1·4-2·7; p<0·0001). No adverse events related to study participation were reported. INTERPRETATION The HITSystem intervention is effective and feasible to implement in low-resource settings. The HITSystem algorithms have been modified to include HIV testing at birth, and an adapted HITSystem 2.0 version is supporting HIV-positive pregnant women to prevent perinatal transmission and optimise maternal and infant outcomes. FUNDING National Institute of Child Health and Human Development.
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Affiliation(s)
| | | | - AnLin Cheng
- University of Missouri-Kansas City, School of Medicine, Kansas City, MO, USA
| | - Catherine Wexler
- Department of Family Medicine, University of Kansas Medical Center, Kansas City, KS, USA
| | - May Maloba
- Global Health Innovations, Nairobi, Kenya
| | - Niaman Nazir
- Department of Preventive Medicine, University of Kansas Medical Center, Kansas City, KS, USA
| | - Samoel Khamadi
- Center for Virus Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Raphael Lwembe
- Center for Virus Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Melinda Brown
- Department of Family Medicine, University of Kansas Medical Center, Kansas City, KS, USA
| | - Thomas A Odeny
- University of Missouri-Kansas City, School of Medicine, Kansas City, MO, USA; Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Jacinda K Dariotis
- College of Education, Criminal Justice, and Human Services, University of Cincinatti, Cincinatti, OH, USA
| | - Matthew Sandbulte
- Department of Family Medicine, University of Kansas Medical Center, Kansas City, KS, USA
| | - Natabhona Mabachi
- Department of Family Medicine, University of Kansas Medical Center, Kansas City, KS, USA
| | - Kathy Goggin
- University of Missouri-Kansas City, School of Medicine, Kansas City, MO, USA; Children's Mercy Kansas City, Health Services and Outcomes Research, Kansas City, MO, USA
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Wexler C, Brown M, Hurley EA, Ochieng M, Goggin K, Gautney B, Maloba M, Lwembe R, Khamadi S, Finocchario-Kessler S. Implementing eHealth Technology to Address Gaps in Early Infant Diagnosis Services: Qualitative Assessment of Kenyan Provider Experiences. JMIR Mhealth Uhealth 2018; 6:e169. [PMID: 30135052 PMCID: PMC6125609 DOI: 10.2196/mhealth.9725] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Revised: 04/27/2018] [Accepted: 06/21/2018] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Literature suggests that electronic health (eHealth) interventions can improve the efficiency and accuracy of health service delivery and improve health outcomes and are generally well received by patients; however, there are limited data on provider experiences using eHealth interventions in resource-limited settings. The HIV Infant Tracking System (HITSystem) is an eHealth intervention designed to improve early infant diagnosis (EID) outcomes among HIV-exposed infants. OBJECTIVE We aimed to compare provider experiences with standard EID and HITSystem implementation at 6 Kenyan hospitals and 3 laboratories. The objective of this study was to better understand provider experiences implementing and using the HITSystem in order to assess facilitators and barriers that may impact adoption and sustainability of this eHealth intervention. METHODS As part of a randomized controlled trial to evaluate the HITSystem, we conducted semistructured interviews with 17 EID providers at participating intervention and control hospitals and laboratories. RESULTS Providers emphasized the perceived usefulness of the HITSystem, including improved efficiency in sample tracking and patient follow-up, strengthened communication networks among key stakeholders, and improved capacity to meet patient needs compared to standard EID. These advantages were realized from an intervention that providers saw as easy to use and largely compatible with workflow. However, supply stock outs and patient psychosocial factors (including fear of HIV status disclosure and poverty) provided ongoing challenges to EID service provision. Furthermore, slow or sporadic internet access and heavy workload prevented real-time HITSystem data entry for some clinicians. CONCLUSIONS Provider experiences with the HITSystem indicate that the usefulness of the HITSystem, along with the ease with which it is able to be incorporated into hospital workflows, contributes to its sustained adoption and use in Kenyan hospitals. To maximize implementation success, care should be taken in intervention design and implementation to ensure that end users see clear advantages to using the technology and to account for variations in workflows, patient populations, and resource levels by allowing flexibility to suit user needs. TRIAL REGISTRATION ClinicalTrials.gov NCT02072603; https://clinicaltrials.gov/ct2/show/NCT02072603 (Archived by WebCite at http://www.webcitation.org/71NgMCrAm).
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Affiliation(s)
- Catherine Wexler
- Department of Family Medicine, University of Kansas Medical Center, Kansas City, KS, United States
| | - Melinda Brown
- Department of Family Medicine, University of Kansas Medical Center, Kansas City, KS, United States
| | - Emily A Hurley
- Health Services and Outcomes Research, Children's Mercy Kansas City, Kansas City, MO, United States
| | | | - Kathy Goggin
- Health Services and Outcomes Research, Children's Mercy Kansas City, Kansas City, MO, United States.,School of Medicine, University of Missouri-Kansas City, Kansas City, MO, United States.,School of Pharmacy, University of Missouri-Kansas City, Kansas City, MO, United States
| | - Brad Gautney
- Global Health Innovations, Dallas, TX, United States
| | - May Maloba
- Global Health Innovations, Dallas, TX, United States
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Wexler C, Cheng AL, Gautney B, Finocchario-Kessler S, Goggin K, Khamadi S. Evaluating turnaround times for early infant diagnosis samples in Kenya from 2011-2014: A retrospective analysis of HITSystem program data. PLoS One 2017; 12:e0181005. [PMID: 28796791 PMCID: PMC5552093 DOI: 10.1371/journal.pone.0181005] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Accepted: 06/23/2017] [Indexed: 01/08/2023] Open
Abstract
Long turnaround times (TAT) for the processing and posting of results of infant HIV DNA PCR samples can hinder the success of early infant diagnosis (EID) programs. The HITSystem is an eHealth intervention that alerts staff when services are overdue or results are delayed. We conducted a retrospective analysis of 3669 HIV-exposed infants enrolled in 15 Kenya hospital EID programs and three laboratories using the HITSystem from 2011–2014. We assessed mean and median TAT from when a sample was: 1) obtained to when it was shipped to the laboratory, 2) shipped to when it was received at the laboratory, 3) received to when a result was posted, and 4) the total time from obtaining the sample (step 1) to posting the result (step 3). TAT were compared by laboratory, clinic, year, and month of sample collection. 3625 infant samples had results posted by end of 2014. Mean TAT from sample collection to shipping was 5.2 days, from shipping to laboratory receipt was 2.0 days, and from laboratory receipt to result posting was 17.4 days. Altogether, it took an average of 24.7 days from sample collection until result posting. There was significant variation between laboratories, particularly in laboratory processing times (step 3). TAT showed a decreasing trend from 2011–2014, although TAT in December remained higher. Compared with other Kenyan studies, TAT in these HITSystem enrolled settings were shorter. Significant variation between laboratories, however, indicates the need to strengthen protocols and infrastructure to ensure that all laboratories can provide rapid, high-quality services.
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Affiliation(s)
- Catherine Wexler
- University of Kansas Medical Center, Department of Family Medicine, Kansas City, Kansas, United States of America
- * E-mail:
| | - An-Lin Cheng
- University of Missouri-Kansas City, School of Medicine, Kansas City, Missouri, United States of America
| | - Brad Gautney
- Global Health Innovations, Kansas City, Missouri, United States of America
| | - Sarah Finocchario-Kessler
- University of Kansas Medical Center, Department of Family Medicine, Kansas City, Kansas, United States of America
| | - Kathy Goggin
- Children’s Mercy Hospitals and Clinics, Health Services and Outcomes Research, Kansas City, Missouri, United States of America
- University of Missouri-Kansas City, School of Medicine, Kansas City, Missouri, United States of America
- University of Missouri-Kansas City, School of Pharmacy, Kansas City, Missouri, United States of America
| | | | - HITSystem Team
- Global Health Innovations, Kansas City, Missouri, United States of America
- Kenya Medical Research Institute, Nairobi, Kenya
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Dundar E, Wexler C, Firlej L, Llewellin P, Kuchta B. Evolution of methane density during melting in nanopores. J Mol Model 2017; 23:44. [PMID: 28154981 DOI: 10.1007/s00894-017-3211-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2016] [Accepted: 01/09/2017] [Indexed: 11/28/2022]
Abstract
Phase properties of gases adsorbed in small nanopores are mainly determined by the pore size and shape as well as the structural heterogeneity of the adsorbate. Here we analyze the evolution of the melting mechanism that occurs in pores <3 nm in size. Melting in slit-shaped graphene pores is compared with melting in SURMOF channel pores with square cross-sections. We show how the melting transformation is related to the adsorption mechanism. We use a graphical representation of the evolution of molecular density as a function of temperature in the nanopores.
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Affiliation(s)
- E Dundar
- Aix Marseille University, CNRS, MADIREL (UMR 7246), 13397, Marseille, France
| | - C Wexler
- Department of Physics and Astronomy, University of Missouri, Columbia, MO, 65211, USA
| | - L Firlej
- Department of Physics and Astronomy, University of Missouri, Columbia, MO, 65211, USA.,Laboratoire Charles Coulomb (L2C), UMR 5221, Université de Montpellier, Montpellier, France
| | - Ph Llewellin
- Aix Marseille University, CNRS, MADIREL (UMR 7246), 13397, Marseille, France
| | - B Kuchta
- Aix Marseille University, CNRS, MADIREL (UMR 7246), 13397, Marseille, France. .,Department of Physics and Astronomy, University of Missouri, Columbia, MO, 65211, USA. .,Department of Chemistry, Wroclaw University of Technology, 50-370, Wroclaw, Poland.
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Affiliation(s)
- E. Dundar
- Aix Marseille Université, CNRS, MADIREL (UMR 7246), 13397 Marseille, France
| | - P. Boulet
- Aix Marseille Université, CNRS, MADIREL (UMR 7246), 13397 Marseille, France
| | - C. Wexler
- Department of Physics and Astronomy, University of Missouri, Columbia, Missouri 65211, USA
| | - L. Firlej
- Laboratoire Charles Coulomb (L2C), UMR5221, Université de Montpellier, 34095 Montpellier, France
| | - Ph. Llewellyn
- Aix Marseille Université, CNRS, MADIREL (UMR 7246), 13397 Marseille, France
| | - B. Kuchta
- Aix Marseille Université, CNRS, MADIREL (UMR 7246), 13397 Marseille, France
- Department of Chemistry, Wroclaw University of Science and Technology, 50-370 Wroclaw, Poland
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Goggin K, Wexler C, Nazir N, Staggs VS, Gautney B, Okoth V, Khamadi SA, Ruff A, Sweat M, Cheng AL, Finocchario-Kessler S. Predictors of Infant Age at Enrollment in Early Infant Diagnosis Services in Kenya. AIDS Behav 2016; 20:2141-50. [PMID: 27108002 PMCID: PMC4995224 DOI: 10.1007/s10461-016-1404-z] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Despite the importance of early detection to signal lifesaving treatment initiation for HIV+ infants, early infant diagnosis (EID) services have received considerably less attention than other aspects of prevention of mother to child transmission care. This study draws on baseline data from an on-going cluster randomized study of an intervention to improve EID services at six government hospitals across Kenya. Two logistic regressions examined potential predictors of “on time” (infant ≤6 weeks of age) vs. “late” (≥7 weeks) and “on time” versus “very late” (≥12 weeks) EID engagement among 756 mother-infant pairs. A quarter of the infants failed to get “on time” testing. Predictors of “on time” testing included being informed about EID by providers when pregnant, perceiving less HIV stigma, and mother’s level of education. Predictors of “very late” testing (≥12 weeks of age) included not being informed about EID by providers when pregnant and living farther from services. Findings highlight the importance of ensuring that health care providers actively and repeatedly inform HIV+ mothers of the availability of EID services, reduce stigma by frequently communicating judgment free support, and assisting mothers in early planning for accessing EID services. Extra care should be focused on engaging mothers with less formal education who are at increased risk for seeking “late” EID testing. This study offers clear targets for improving services so that all HIV-exposed infants can be properly engaged in EID services, thus increasing the potential for the best possible outcomes for this vulnerable population.
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Affiliation(s)
- Kathy Goggin
- Children's Mercy Hospitals and Clinics, Health Services and Outcomes Research, 2401 Gillham Road, Kansas City, MO, 64108, USA.
- University of Missouri-Kansas City, School of Medicine, Kansas City, MO, USA.
- University of Missouri-Kansas City, School of Pharmacy, Kansas City, MO, USA.
| | - Catherine Wexler
- University of Kansas Medical Center, Department of Family Medicine, Kansas City, KS, USA
| | - Niaman Nazir
- University of Kansas Medical Center, Department of Preventive Medicine, Kansas City, KS, USA
| | - Vincent S Staggs
- Children's Mercy Hospitals and Clinics, Health Services and Outcomes Research, 2401 Gillham Road, Kansas City, MO, 64108, USA
- University of Missouri-Kansas City, School of Medicine, Kansas City, MO, USA
| | | | | | | | - Andrea Ruff
- Johns Hopkins Bloomberg School of Public Health, Department of International Health, Baltimore, MD, USA
| | - Michael Sweat
- Medical University of South Carolina, Department of Psychiatry and Behavioral Sciences, Charleston, SC, USA
| | - An-Lin Cheng
- University of Missouri-Kansas City, School of Nursing and Health Studies, Kansas City, MO, USA
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Finocchario-Kessler S, Wexler C, Maloba M, Mabachi N, Ndikum-Moffor F, Bukusi E. Cervical cancer prevention and treatment research in Africa: a systematic review from a public health perspective. BMC Womens Health 2016; 16:29. [PMID: 27259656 PMCID: PMC4893293 DOI: 10.1186/s12905-016-0306-6] [Citation(s) in RCA: 102] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2015] [Accepted: 05/21/2016] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Women living in Africa experience the highest burden of cervical cancer. Research and investment to improve vaccination, screening, and treatment efforts are critically needed. We systematically reviewed and characterized recent research within a broader public health framework to organize and assess the range of cervical cancer research in Africa. METHODS We searched online databases and the Internet for published articles and cervical cancer reports in African countries. Inclusion criteria included publication between 2004 and 2014, cervical cancer-related content pertinent to one of the four public health categories (primary, secondary, tertiary prevention or quality of life), and conducted in or specifically relevant to countries or regions within the African continent. The study design, geographic region/country, focus of research, and key findings were documented for each eligible article and summarized to illustrate the weight and research coverage in each area. Publications with more than one focus (e.g. secondary and tertiary prevention) were categorized by the primary emphasis of the paper. Research specific to HIV-infected women or focused on feasibility issues was delineated within each of the four public health categories. RESULTS A total of 380 research articles/reports were included. The majority (54.6 %) of cervical cancer research in Africa focused on secondary prevention (i.e., screening). The number of publication focusing on primary prevention (23.4 %), particularly HPV vaccination, increased significantly in the past decade. Research regarding the treatment of precancerous lesions and invasive cervical cancer is emerging (17.6 %), but infrastructure and feasibility challenges in many countries have impeded efforts to provide and evaluate treatment. Studies assessing aspects of quality of life among women living with cervical cancer are severely limited (4.1 %). Across all categories, 11.3 % of publications focused on cervical cancer among HIV-infected women, while 17.1 % focused on aspects of feasibility for cervical cancer control efforts. CONCLUSIONS Cervical cancer research in African countries has increased steadily over the past decade, but more is needed. Tertiary prevention (i.e. treatment of disease with effective medicine) and quality of life of cervical cancer survivors are two severely under-researched areas. Similarly, there are several countries in Africa with little to no research ever conducted on cervical cancer.
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Affiliation(s)
| | - Catherine Wexler
- Department of Family Medicine, University of Kansas Medical Center, Kansas City, USA
| | - May Maloba
- Family AIDS Care and Education Services, Kenya Medical Research Institute, Kisumu, Kenya
| | - Natabhona Mabachi
- Department of Family Medicine, University of Kansas Medical Center, Kansas City, USA
| | - Florence Ndikum-Moffor
- Department of Preventive Medicine and Public Health, University of Kansas Medical Center, Kansas City, USA
| | - Elizabeth Bukusi
- Family AIDS Care and Education Services, Kenya Medical Research Institute, Kisumu, Kenya
- Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
- Department of Obstetrics and Gynecology, University of Nairobi, Nairobi, Kenya
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Rosenberg AA, Branscomb LM, Eady V, Frumhoff PC, Goldman GT, Halpern M, Kimmell K, Kothari Y, Kramer LD, Lane N, McCarthy J, Phartiyal P, Rest K, Sims R, Wexler C. Science in Congress: Deceptive statistics—Response. Science 2015; 349:487. [DOI: 10.1126/science.349.6247.487-a] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Affiliation(s)
- Andrew A. Rosenberg
- Center for Science and Democracy, Union of Concerned Scientists, Cambridge, MA 02138, USA
| | - L. M. Branscomb
- University of California, San Diego, La Jolla, CA 92093, USA
| | - V. Eady
- Conservation Law Foundation, Boston, MA 02110, USA
| | | | - G. T. Goldman
- Center for Science and Democracy, Union of Concerned Scientists, Cambridge, MA 02138, USA
| | - M. Halpern
- Center for Science and Democracy, Union of Concerned Scientists, Cambridge, MA 02138, USA
| | - K. Kimmell
- Union of Concerned Scientists, Cambridge, MA 02138, USA
| | - Y. Kothari
- Center for Science and Democracy, Union of Concerned Scientists, Cambridge, MA 02138, USA
| | - L. D. Kramer
- William and Flora Hewlett Foundation, Menlo Park, CA 94025, USA
| | - N.F. Lane
- Baker Institute of Public Policy, Rice University, Houston, TX 77005, USA
| | | | - P. Phartiyal
- Center for Science and Democracy, Union of Concerned Scientists, Cambridge, MA 02138, USA
| | - K. Rest
- Union of Concerned Scientists, Cambridge, MA 02138, USA
| | | | - C. Wexler
- Center for Science and Democracy, Union of Concerned Scientists, Cambridge, MA 02138, USA
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Rosenberg AA, Branscomb LM, Eady V, Frumhoff PC, Goldman GT, Halpern M, Kimmell K, Kothari Y, Kramer LD, Lane NF, McCarthy JJ, Phartiyal P, Rest K, Sims R, Wexler C. Congress's attacks on science-based rules. Science 2015; 348:964-6. [DOI: 10.1126/science.aab2939] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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Romanos J, Beckner M, Rash T, Firlej L, Kuchta B, Yu P, Suppes G, Wexler C, Pfeifer P. Nanospace engineering of KOH activated carbon. Nanotechnology 2012; 23:015401. [PMID: 22156024 DOI: 10.1088/0957-4484/23/1/015401] [Citation(s) in RCA: 122] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
This paper demonstrates that nanospace engineering of KOH activated carbon is possible by controlling the degree of carbon consumption and metallic potassium intercalation into the carbon lattice during the activation process. High specific surface areas, porosities, sub-nanometer (<1 nm) and supra-nanometer (1-5 nm) pore volumes are quantitatively controlled by a combination of KOH concentration and activation temperature. The process typically leads to a bimodal pore size distribution, with a large, approximately constant number of sub-nanometer pores and a variable number of supra-nanometer pores. We show how to control the number of supra-nanometer pores in a manner not achieved previously by chemical activation. The chemical mechanism underlying this control is studied by following the evolution of elemental composition, specific surface area, porosity, and pore size distribution during KOH activation and preceding H(3)PO(4) activation. The oxygen, nitrogen, and hydrogen contents decrease during successive activation steps, creating a nanoporous carbon network with a porosity and surface area controllable for various applications, including gas storage. The formation of tunable sub-nanometer and supra-nanometer pores is validated by sub-critical nitrogen adsorption. Surface functional groups of KOH activated carbon are studied by microscopic infrared spectroscopy.
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Affiliation(s)
- J Romanos
- Department of Physics and Astronomy, University of Missouri, Columbia, MO 65211, USA.
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Wexler C, Firlej L, Kuchta B, Roth MW. Melting of hexane monolayers adsorbed on graphite: the role of domains and defect formation. Langmuir 2009; 25:6596-6598. [PMID: 19425600 DOI: 10.1021/la900808f] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
We present the first large-scale molecular dynamics simulations of hexane on graphite that completely reproduce all experimental features of the melting transition. The canonical ensemble simulations required and used the most realistic model of the system: (i) a fully atomistic representation of hexane; (ii) an explicit site-by-site interaction with carbon atoms in graphite; (iii) the CHARMM force field with carefully chosen adjustable parameters of nonbonded interaction, and (iv) numerous >or=100 ns runs, requiring a total computation time of ca. 10 CPU years. The exhaustive studies have allowed us to determine the mechanism of the transition: proliferation of small domains through molecular reorientation within lamellae and without perturbation of the overall adsorbed film structure. At temperatures greater than that of melting, the system exhibits dynamically reorienting domains whose orientations reflect the graphite substrate's symmetry and whose size decrease with increasing temperature.
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Affiliation(s)
- C Wexler
- University of Missouri, Department of Physics and Astronomy, Columbia, Missouri 65211, USA
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Pfeifer P, Aston L, Banks M, Barker S, Burress J, Carter S, Coleman J, Crockett S, Faulhaber C, Flavin J, Gordon M, Hardcastle L, Kallenborn Z, Kemiki M, Lapilli C, Pobst J, Schott R, Shah P, Spellerberg S, Suppes G, Taylor D, Tekeei A, Wexler C, Wood M, Buckley P, Breier T, Downing J, Eastman S, Freeze P, Graham S, Grinter S, Howard A, Martinez J, Radke D, Vassalli T, Ilavsky J. Complex pore spaces create record-breaking methane storage system for natural-gas vehicles. Chaos 2007; 17:041108. [PMID: 18163763 DOI: 10.1063/1.2786007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Affiliation(s)
- P Pfeifer
- University of Missouri, Columbia, Missouri 65211, USA
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Vilke G, Johnson W, Castillo E, Ederheimer J, Wexler C, Sloane C, Chan T. 75. Ann Emerg Med 2006. [DOI: 10.1016/j.annemergmed.2006.07.523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Affiliation(s)
- R N Bitton
- Division of Endocrinology, Long Island Jewish Medical Center, New Hyde Park, New York, New York 11042
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Soller M, Brody T, Eitan Y, Agursky T, Wexler C. Minimum weight for onset of sexual maturity in female chickens: heritability and phenotypic and genetic correlations with early growth rate. Poult Sci 1984; 63:2103-13. [PMID: 6514658 DOI: 10.3382/ps.0632103] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
The heritability of minimum weight for onset of sexual maturity in chickens (WTSXM) and its phenotypic and genetic correlations with early growth rate were studied in a Leghorn (L) layer stock, in two White Rock (WR) broiler stocks, and in the F4, F5, and F6 segregating generations of a White Rock X Leghorn (WR X L) cross. Mean heritability of WTSXM was .38 in the WR populations and .84 in the WR X L cross populations. Mean WTSXM of the various genetic stocks were closely related to their mean early growth rate. The mean phenotypic correlation of WTSXM and early growth rate was .07 in the WR populations but .47 in the WR X L cross populations. Estimates of the genetic correlation of WTSXM with early growth rate were high, and uniform in sign in the WR X L cross populations but smaller in magnitude and variable in sign in the WR populations. The implications of these results with respect to WTSXM as a breeding objective are discussed.
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