Festus Ilako

Long-Term Adherence to Antiretroviral Treatment and Program Drop-Out in a High-Risk Urban Setting in Sub-Saharan Africa: A Prospective Cohort Study

Background Seventy percent of urban populations in sub-Saharan Africa live in slums. Sustaining HIV patients in these high-risk and highly mobile settings is a major future challenge. This study seeks to assess program retention and to find determinants for low adherence to antiretroviral treatment (ART) and drop-out from an established HIV/ART program in Kibera, Nairobi, one of Africas largest informal urban settlements. Methods and Findings A prospective open cohort study of 800 patients was performed at the African Medical Research Foundation (AMREF) clinic in the Kibera slum. Adherence to ART and drop-out from the ART program were independent outcomes. Two different adherence measures were used: (1) “dose adherence” (the proportion of a prescribed dose taken over the past 4 days) and (2) “adherence index” (based on three adherence questions covering dosing, timing and special instructions). Drop-out from the program was calculated based on clinic appointment dates and number of prescribed doses, and a patient was defined as being lost to follow-up if over 90 days had expired since the last prescribed dose. More than one third of patients were non-adherent when all three aspects of adherence – dosing, timing and special instructions – were taken into account. Multivariate logistic regression revealed that not disclosing HIV status, having a low level of education, living below the poverty limit (US

Challenges for Scaling up ART in a Resource-Limited Setting : A Retrospective Study in Kibera, Kenya

2/day) and not having a treatment buddy were significant predictors for non-adherence. Additionally, one quarter of patients dropped out for more than 90 days after the last prescribed ART dose. Not having a treatment buddy was associated with increased risk for drop-out (hazard ratio 1.4, 95% CI = 1.0–1.9). Conclusion These findings point to the dilemma of trying to sustain a growing number of people on life-long ART in conditions where prevailing stigma, poverty and food shortages threatens the long-term success of HIV treatment.

Sexual risk taking among patients on antiretroviral therapy in an urban informal settlement in Kenya: a cross-sectional survey

Objective:To determine levels of dropout and adherence in an antiretroviral treatment (ART) program in sub-Saharan Africas largest urban informal settlement, Kibera, in Nairobi, Kenya. Method:Retrospective cohort study. Results:Of 830 patients that started ART between January 2005 and September 2007, 29% dropped out of the program for more than 90 days at least once after the last prescribed dose. The dropout rate was 23 per 100 person-years, and the probability of retention in the program at 6, 12, and 24 months was 0.83, 0.74, and 0.65, respectively. Twenty-seven percent of patients had an overall mean adherence below 95%. Being a resident of Kibera was significantly associated with 11 times higher risk of dropout. Conclusion:Despite free drugs and low associated costs, dropout probabilities in this study are higher and adherence to ART is lower compared with other studies from sub-Saharan Africa. Our results illustrate that ART programs in resource-limited settings, such as Kibera, risk low adherence and retention rates when expanding services. Specific and intensified patient support is needed to minimize the risk of dropout and nonadherence causing future significant health threats not only to individuals but also to public health.

The influence of traditional medicine and religion on discontinuation of ART in an urban informal settlement in Nairobi, Kenya.

BackgroundOur intention was to analyze demographic and contextual factors associated with sexual risk taking among HIV-infected patients on antiretroviral treatment (ART) in Africas largest informal urban settlement, Kibera in Nairobi, Kenya.MethodsWe used a cross-sectional survey in a resource-poor, urban informal settlement in Nairobi; 515 consecutive adult patients on ART attending the African Medical and Research Foundation clinic in Kibera in Nairobi were included in the study. Interviewers used structured questionnaires covering socio-demographic characteristics, time on ART, number of sexual partners during the previous six months and consistency of condom use.ResultsTwenty-eight percent of patients reported inconsistent condom use. Female patients were significantly more likely than men to report inconsistent condom use (aOR 3.03; 95% CI 1.60-5.72). Shorter time on ART was significantly associated with inconsistent condom use. Multiple sexual partners were more common among married men than among married women (adjusted OR 4.38; 95% CI 1.82-10.51).ConclusionsInconsistent condom use was especially common among women and patients who had recently started ART, i.e., when the risk of HIV transmission is higher. Having multiple partners was quite common, especially among married men, with the potential of creating sexual networks and an increased risk of HIV transmission. ART needs to be accompanied by other preventive interventions to reduce the risk of new HIV infections among sero-discordant couples and to increase overall community effectiveness.

A Program to Provide Antiretroviral Therapy to Residents of an Urban Slum in Nairobi, Kenya:

Abstract Objective. The objective of this study was to explore the influence of traditional medicine and religion on discontinuation of antiretroviral therapy (ART) in one of Africas largest informal urban settlement, Kibera, in Nairobi, Kenya. Methods. Semi-structured face-to-face interviews were conducted with 20 patients discontinuing the African Medical and Research Foundation (AMREF) ART program in Kibera due to issues related to traditional medicine and religion. Results. Traditional medicine and religion remain important in many peoples lives after ART initiation, but these issues are rarely addressed in a positive way during ART counseling. Many patients found traditional medicine and their religious beliefs to be in conflict with clinic treatment advice. Patients described a decisional process, prior to the actual drop-out from the ART program that involved a trigger event, usually a specific religious event, or a meeting with someone using traditional medicine that influenced them to take the decision to stop ART. Conclusion. Discontinuation of ART could be reduced if ART providers acknowledged and addressed the importance of religious issues and traditional medicine in the lives of patients, especially in similar resource-poor settings. Telling patients not to mix ART and traditional medicine appeared counter-productive in this setting. Introducing an open discussion around religious beliefs and the pros and cons of traditional medicine as part of standard counseling, may prevent drop-out from ART when side effects or opportunistic infections occur.

Adverse Events in HIV-Infected Persons Receiving Antiretroviral Drug Regimens in a Large Urban Slum in Nairobi, Kenya, 2003-2005

Objective: To evaluate retention in care and response to therapy for patients enrolled in an antiretroviral treatment program in a severely resource-constrained setting. Methods: We evaluated patients enrolled between February 26, 2003, and February 28, 2005, in a community clinic in Kibera, an informal settlement, in Nairobi, Kenya. Midlevel providers offered simplified, standardized antiretroviral therapy (ART) regimens and monitored patients clinically and with basic laboratory tests. Clinical, immunologic, and virologic indicators were used to assess response to ART; adherence was determined by 3-day recall. A total of 283 patients (70% women; median baseline CD4 count, 157 cells/ mm3; viral load, 5.16 log copies/mL) initiated ART and were followed for a median of 7.1 months (n = 2384 patient-months). Results: At 1 year, the median CD4 count change was +124.5 cells/mm3 (n = 74; interquartile range, 42 to 180), and 71 (74%) of 96 patients had viral load <400 copies/mL. The proportion of patients reporting 100% adherence over the 3 days before monthly clinic visits was 94% to 100%. As of February 28, 2005, a total of 239 patients (84%) remained in care, 22 (8%) were lost to follow-up, 12 (4%) were known to have died, 5 (2%) had stopped ART, 3 (1%) moved from the area, and 2 (< 1% ) transferred care. Conclusions: Response to ART in this slum population was comparable to that seen in industrialized settings. With government commitment, donor support, and community involvement, it is feasible to implement successful ART programs in extremely challenging social and environmental conditions.

'Keeping healthy in the backseat': How motherhood interrupted HIV treatment in recently delivered women in Kenya.

Objective : This article describes toxicities to antiretroviral therapy (ART) among HIV-infected patients receiving care at a clinic in a large urban slum in Nairobi, Kenya. Methods: Patients were treated with nonnucleoside reverse transcriptase inhibitor-based ART and followed at scheduled intervals. Frequencies and cumulative probabilities of toxicities were calculated. Results: Among 283 patients starting ART, any and severe clinical toxicity were recorded as 65% and 6%, respectively. Cumulative probabilities for remaining free of any and severe clinical toxicities at 6, 12, and 18 months, were 0.47, 0.26, and 0.17, respectively and 0.98, 0.95, and 0.89, respectively. The probability of remaining free from elevated and grade 3 or 4 serum aminotransferase (AST) at 6, 12, and 18 months were 0.62, 0.42, and 0.21, respectively, and 0.99 at 6, 12, and 18 months. Conclusions: ART toxicities were frequent, but severe toxicities were less common. In resource-limited settings, ART toxicity should not represent a barrier to care.

Sexual risk-reduction strategies among HIV-infected men receiving ART in Kibera, Nairobi

Although there is a large body of literature related to the experiences of motherhood and aspects of the change that it brings about, how the experience of motherhood affects the healthcare of women with chronic illness is less documented. This study explores how motherhood in newly delivered HIV-infected mothers in Kenya interrupted their antiretroviral treatment (ART). Qualitative interviews were performed with 26 mothers on ART in a rural or urban area. The data were organised and interpreted using content analysis. The study found that adherence to ART was influenced by contextual differences in socio-cultural expectations and family relationships. Urban life enabled women to make decisions on their own and to negotiate challenges that were often unpredictable. Women in rural areas knew what was expected of them and decisions were normally not for them to make alone. The women in Busia and Kibera had difficulties combining adherence with attaining the socio-cultural definition of good mothering. Lack of support from health providers and weak healthcare systems contributed to inadequate stocks of HIV drugs and inaccessibility of HIV-related care. From the data, we developed the main theme ‘keeping healthy in the backseat’ and the two sub-themes ‘regaining self-worth through motherhood’ and ‘mother first – patient later.’ We suggest that motherhood is context-specific and follows socio-cultural practises, which made it difficult for the women in Kenya to follow ART instructions. There is a need to reassess HIV-related services for mothers on ART in order to give them a better chance to stay on treatment and satisfy their aspiration to be ‘good mothers.’ Context-specific HIV-treatment policies are necessary for ensuring adherence and successful treatment outcomes.

Comparing clinic retention between residents and nonresidents of Kibera, Kenya.

Abstract This paper explores motivational factors and barriers to sexual behaviour change among men receiving antiretroviral treatment (ART). Twenty in-depth interviews were undertaken with male patients enrolled at the African Medical and Research Foundation clinic in Africas largest urban informal settlement, Kibera in Nairobi, Kenya. All participants experienced prolonged and severe illness prior to the initiation of ART. Fear of symptom relapse was the main trigger for sexual behaviour change. Partner reduction was reported as a first option for behaviour change since this decision could be made by the individual. Condom use was perceived as more difficult as it had to be negotiated with female partners. Cultural norms regarding expectations for reproduction and marriage were not supportive of sexual risk-reduction strategies. Thus, local sociocultural contexts of HIV-infected people must be incorporated into the contextual adaptation and design of ART programmes and services as they have an over-riding influence on sexual behaviour and programme effectiveness. Also, HIV-prevention interventions need to address both personal, micro- and macro-level factors of behaviour to encourage individuals to take on sexual risk-reduction strategies. In order to achieve the anticipated preventive effect of ART, these issues are important for the donor community and policy-makers, who are the major providers of ART programme support within weak health systems in sub-Saharan Africa.

I will not let my HIV status stand in the way. Decisions on motherhood among women on ART in a slum in Kenya- a qualitative study

treatment (ART) programs in urban slum settings. 1 Our article presented research performed at the African Medical and Research Foundation (AMREF) clinic in Kibera, one of Africa’s largest informal settlements, which showed that being a Kibera resident was significantly associated with ART program drop-out. Additionally, the Cox proportional hazard ratio for dropping-out among Kibera residents was 2.45 (P = 0.05), as compared with non–Kibera residents (result not presented in the original article). Chung et al did not find that Kibera residents who attended their study clinic at the Coptic Hope Centre had a higher loss to follow-up (Cox proportional hazard ratio: 1.02) than non–Kibera residents, and thus ‘‘caution against the conclusion that residing in Kibera or any urban slum is a risk factor for poor retention.’’ However, there are important differences in terms of geographical location, patient catchment area, and resources that make this comparison difficult. First, the Coptic Hope Centre clinic is located outside Kibera, whereas the AMREF clinic is located right in the centre of Kibera. Second Chung et al argue that: ‘‘Some residents are middle class Kenyans with a yearly salary and not necessarily day laborers with low income.’’ The Kibera population has not previously been well described in terms of sociodemographics and in our retrospective study; we lacked valid data on socioeconomic variables. However, our preliminary data from an ongoing prospective cohort study of HIV patients on ART at the AMREF Kibera clinic support our experience that most patients live under extremely poor conditions. Out of 515 ART patients enrolled so far in our prospective study, only 16% are employed, the other 84% are doing casual labor, are unemployed, or self-employed. Further, only 5% of the respondents have higher education (postsecondary school). Hence, our different findings are likely attributable to selection of more motivated and possibly less vulnerable patients from Kibera seeking care at the Coptic Hope Centre. Secondly, Chung et al speculate that patients dropping-out from the AMREF program might have sought care at a PEPFAR-funded clinic instead; however, the AMREF program at the Kibera clinic likewise receives funding from PEPFAR via CDC). We lack quantitative data on reasons for loss to follow-up, but our qualitative in-depth studies among HIV patients who have dropped out from the ART program in Kibera suggest that aside from death, migration, and the occasional patient changing provider, poverty and lack of food appear to be the major barriers to retention in an ART program in Kibera. 2 The time spent on clinic visits is considered better used to look for job opportunities, and taking ART is not perceived compatible with hunger and an empty stomach. In our forthcoming prospective study we will be able to further analyze determinants of retention in care. In addition, we used a more conservative definition of drop-out, 90 days, in order not to over estimate drop-out and to account for short-term migration in the mobile population of Kibera. Chung et al used 30 days as the cut-off. The Coptic Hope Centre clinic included only treatment-naive patients from the age of 15 years, whereas we included both treatmentnaive and treatment-experienced patients above the age of 18 years. Our results might thus