Matthew D. Hickey

Antiretroviral concentrations in small hair samples as a feasible marker of adherence in rural Kenya.

Abstract:Antiretroviral hair levels objectively quantify drug exposure over time and predict virologic responses. We assessed the acceptability and feasibility of collecting small hair samples in a rural Kenyan cohort. Ninety-five percentage of participants (354/373) donated hair. Although median self-reported adherence was 100% (interquartile range, 96%–100%), a wide range of hair concentrations likely indicates overestimation of self-reported adherence and the advantages of a pharmacologic adherence measure. Higher nevirapine hair concentrations observed in women and older adults require further study to unravel behavioral versus pharmacokinetic contributors. In resource-limited settings, hair antiretroviral levels may serve as a low-cost quantitative biomarker of adherence.

Around the Table: Food Insecurity, Socioeconomic Status, and Instrumental Social Support among Women Living in a Rural Kenyan Island Community

The objective of this study was to investigate the relationship among socioeconomic status, social support, and food insecurity in a rural Kenyan island community. A cross-sectional random sample of 111 female heads of households representing 583 household members were surveyed in Mfangano Island, Kenya from August to October 2010 using adaptations of the Household Food Insecurity Access Scale and the Medical Outcomes Study Social Support Survey. In multiple linear regression models, less instrumental social support, defined as concrete direct ways people help others (B = –0.81; 95% confidence interval [CI] –1.45 to –0.17), and decreased ownership scale based on owning material assets (B = –2.93; 95% CI –4.99 to –0.86) were significantly associated with increased food insecurity, controlling for age, education, marital status, and household size. Social support interventions geared at group capacity and resilience may be crucial adjuncts to improve and maintain the long term food security and health of persons living in low-resource regions.

Use of rifabutin for the treatment of a latent tuberculosis infection in a patient after solid organ transplantation

Latent tuberculosis infection is an important problem for solid organ transplant recipients because of the frequency of its occurrence and its potential for reactivation. Because of the high mortality rate associated with active tuberculosis infections in transplant recipients, guidelines from the American Thoracic Society recommend treatment for latent tuberculosis in this population. However, the choice of treatments is often difficult because liver transplant recipients may be more sensitive to isoniazid hepatotoxicity, and rifampin has significant drug interactions with the calcineurin inhibitors used for immunosuppression. Two prior case reports described success with the use of rifabutin, a rifampin alternative, as part of a multidrug treatment regimen for active tuberculosis in posttransplant patients; however, there is no prior literature describing any experience with rifabutin for the treatment of latent tuberculosis in the posttransplant setting. We present a summary of tacrolimus drug levels and corresponding dose requirements for a single posttransplant patient during the administration of 3 different latent tuberculosis drug regimens: rifampin alone, rifampin plus ketoconazole, and rifabutin. In this patients case, rifabutin allowed the maintenance of adequate tacrolimus levels, although an approximate 2.5‐fold increase in the dose was required. Rifampin alone was associated with inadequate immunosuppressant levels, and rifampin plus ketoconazole was associated with a problematically prolonged QT interval and concerns about inadequate tuberculosis treatment. Liver Transpl 19:457–461, 2013.

Pulling the network together: quasi-experimental trial of a patient-defined support network intervention for promoting engagement in HIV care and medication adherence on Mfangano Island, Kenya

Background:Despite progress in the global scale-up of antiretroviral therapy, sustained engagement in HIV care remains challenging. Social capital is an important factor for sustained engagement, but interventions designed to harness this powerful social force are uncommon. Methods:We conducted a quasiexperimental study evaluating the impact of the Microclinic Social Network intervention on engagement in HIV care and medication adherence on Mfangano Island, Kenya. The intervention was introduced into 1 of 4 similar communities served by this clinic; comparisons were made between communities using an intention-to-treat analysis. Microclinics, composed of patient-defined support networks, participated in 10 biweekly discussion sessions covering topics ranging from HIV biology to group support and group HIV status disclosure. Nevirapine concentrations in hair were measured before and after study. Results:One hundred thirteen (74%) intervention community participants joined a microclinic group, 86% of whom participated in group HIV status disclosure. Over 22-month follow-up, intervention community participants experienced one-half the rate of ≥90-day clinic absence as those in control communities (adjusted hazard ratio: 0.48; 95% confidence interval: 0.25 to 0.92). Nevirapine hair levels declined in both study arms; in adjusted linear regression analysis, the decline was 6.7 ng/mg less severe in the intervention arm than control arm (95% confidence interval: −2.7 to 16.1). Conclusions:The microclinic intervention is a promising and feasible community-based strategy to improve long-term engagement in HIV care and possibly medication adherence. Reducing treatment interruptions using a social network approach has important implications for individual patient virologic suppression, morbidity, and mortality and for broader community empowerment and engagement in healthcare.

Movement between facilities for HIV care among a mobile population in Kenya: transfer, loss to follow-up, and reengagement

ABSTRACT HIV treatment is life-long, yet many patients travel or migrate for their livelihoods, risking treatment interruption. We examine timely reengagement in care among patients who transferred-out or were lost-to-follow-up (LTFU) from a rural HIV facility. We conducted a cohort study among 369 adult patients on antiretroviral therapy between November 2011 and November 2013 on Mfangano Island, Kenya. Patients who transferred or were LTFU (i.e., missed a scheduled appointment by ≥90 days) were traced to determine if they reengaged or accessed care at another clinic. We report cumulative incidence and time to reengagement using Cox proportional hazards models adjusted for patient demographic and clinical characteristics. Among 369 patients at the clinic, 23(6%) requested an official transfer and 78(21%) were LTFU. Among official transfers, cumulative incidence of linkage to their destination facility was 91% at three months (95%CI (confidence intervals) 69–98%). Among LTFU, cumulative incidence of reengagement in care at the original or a new clinic was 14% at three months (95%CI 7–23%) and 60% at six months (95%CI 48–69%). In the adjusted Cox model, patients who left with an official transfer reengaged in care six times faster than those who did not (adjusted hazard ratio 6.2, 95%CI 3.4–11.0). Patients who left an island-based HIV clinic in Kenya with an official transfer letter reengaged in care faster than those who were LTFU, although many in both groups had treatment gaps long enough to risk viral rebound. Better coordination of transfers between clinics, such as assisting patients with navigating the process or improving inter-clinic communication surrounding transfers, may reduce delays in treatment during transfer and improve overall clinical outcomes.

Human health alters the sustainability of fishing practices in East Africa

Significance We accept that the environment influences human health, but we know little about how human health affects the environment. However, millions of people around the world rely on natural resources for food and livelihoods and confront a high burden of illness. Experience of illness may change people’s physical capacities, outlook, and planning horizons and shape how they engage with the environment. We analyze these impacts in fishing communities of Lake Victoria, Kenya. Although illness may cause the sickest individuals not to fish, many fishers continue fishing but shift their methods. When sick, fishers use methods that are less physically demanding but illegal and environmentally destructive. Our findings suggest that environmental sustainability may be integrally shaped by the health of resource users. Understanding feedbacks between human and environmental health is critical for the millions who cope with recurrent illness and rely directly on natural resources for sustenance. Although studies have examined how environmental degradation exacerbates infectious disease, the effects of human health on our use of the environment remains unexplored. Human illness is often tacitly assumed to reduce human impacts on the environment. By this logic, ill people reduce the time and effort that they put into extractive livelihoods and, thereby, their impact on natural resources. We followed 303 households living on Lake Victoria, Kenya over four time points to examine how illness influenced fishing. Using fixed effect conditional logit models to control for individual-level and time-invariant factors, we analyzed the effect of illness on fishing effort and methods. Illness among individuals who listed fishing as their primary occupation affected their participation in fishing. However, among active fishers, we found limited evidence that illness reduced fishing effort. Instead, ill fishers shifted their fishing methods. When ill, fishers were more likely to use methods that were illegal, destructive, and concentrated in inshore areas but required less travel and energy. Ill fishers were also less likely to fish using legal methods that are physically demanding, require travel to deep waters, and are considered more sustainable. By altering the physical capacity and outlook of fishers, human illness shifted their effort, their engagement with natural resources, and the sustainability of their actions. These findings show a previously unexplored pathway through which poor human health may negatively impact the environment.

Implementation and Operational Research

Background:Many HIV-infected pregnant women identified during antenatal care (ANC) do not enroll in long-term HIV care, resulting in deterioration of maternal health and continued risk of HIV transmission to infants. Methods:We performed a cluster randomized trial to evaluate the effect of integrating HIV care into ANC clinics in rural Kenya. Twelve facilities were randomized to provide either integrated services (ANC, prevention of mother-to-child transmission, and HIV care delivered in the ANC clinic; n = 6 intervention facilities) or standard ANC services (including prevention of mother-to-child transmission and referral to a separate clinic for HIV care; n = 6 control facilities). Results:There were high patient attrition rates over the course of this study. Among study participants who enrolled in HIV care, there was 12-month follow-up data for 256 of 611 (41.8%) women and postpartum data for only 325 of 1172 (28%) women. By 9 months of age, 382 of 568 (67.3%) infants at intervention sites and 338 of 594 (57.0%) at control sites had tested for HIV [odds ratio (OR) 1.45, 95% confidence interval (CI): 0.71 to 2.82]; 7.3% of infants tested HIV positive at intervention sites compared with 8.0% of infants at control sites (OR 0.89, 95% CI: 0.56 to 1.43). The composite clinical/immunologic progression into AIDS was similar in both arms (4.9% vs. 5.1%, OR 0.83, 95% CI: 0.41 to 1.68). Conclusions:Despite the provision of integrated services, patient attrition was substantial in both arms, suggesting barriers beyond lack of service integration. Integration of HIV services into the ANC clinic was not associated with a reduced risk of HIV transmission to infants and did not appear to affect short-term maternal health outcomes.

Evaluation of a Diabetes Education Video Among the Tz'utujil Maya in Guatemala

The prevalence of diabetes is rising throughout Latin America, particularly in the Tz’utujil Maya town of Santiago Atitlan, Guatemala. Major gaps in biomedical knowledge about the causes, chronicity, and long-term complications of diabetes have been reported in rural Guatemala among diabetes patients. In one rural Guatemalan study, respondents believed that ‘‘strong emotions’’ caused diabetes. Diabetes education services are limited in Santiago Atitlan, as the primary language for 94% of the population is Tz’utujil Maya, one of 21 distinct Mayan dialects spoken in Guatemala, and few biomedical clinicians are conversant in this non-written language. To address this need, a health education video was developed for a target audience of Tz’utujil-speaking community residents living with type 2 diabetes mellitus for use by the local hospital and other healthcare posts. Health education videos are an increasingly utilized medium of communication, with over 500 American hospitals currently having produced publicly available health education videos. The purpose of this letter is to provide an evaluation for this Tz’utujil-language diabetes education video. Mixed qualitative and quantitative methods for this study included semistructured interviews and preand post-testing of the video’s content immediately before and after the video screening as a rough metric of understanding and retention. The stratified random sample included 20 community residents (stratified as 17 urban and three rural) who were selected via randomly generated Global Positioning System points on a satellite map of the town. A Tz’utujil–Spanish translator was present to assist with each semistructured interview. Responses from the interviews were captured on digital audio recordings and paper-based field notes. Interviews were conducted between 09:00 and 15:00 h Monday– Friday in March 2010 and typically lasted 30–60 min. SPSS version 12.0 for Windows (SPSS Inc., Chicago, IL) was used to analyze preand post-video responses using v tests and t tests for comparisons of means. The study was approved by the Committee on Human Research at the University of California, San Francisco and the Mayor and Ministry of Health of Santiago Atitlan, Guatemala.

Marginalization and Community Perception of HIV Care, Treatment, and Support on Mfangano Island, Kenya

(1) University of California, Berkeley–University of California, San Francisco Joint Medical Program (UC Berkeley-UCSF JMP); (2) Global Health Sciences, University of California, San Francisco (UCSF); (3) Ventura County Medical Center, Family Medicine Residency Program; (4) Department of Population Medicine and Diagnostic Sciences, Cornell University; (5) Mfangano Island Research Group, Organic Health Response; (6) Division of General Internal Medicine, Department of Medicine, University of California, San Francisco (UCSF); (7) Microclinic International; (8) Department of Family and Community Medicine, University of Minnesota; (9) Kenya Medical Research Institute; (10) Bixby Center for Global Reproductive Health, University of California, San Francisco (UCSF); (11) Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco (UCSF); (12) School of Public Health, University of California, Berkeley (UC Berkeley)

Understanding why HIV-infected persons disengaged from pre-ART care in Freetown, Sierra Leone: a qualitative study

ABSTRACT In countries that have not implemented universal antiretroviral treatment (ART), loss to follow-up (LTFU) during pre-ART care remains a problem. We conducted semi-structured interviews with 41 HIV-infected persons who were LTFU during pre-ART care from a prospective cohort of persons newly diagnosed with HIV infection in Freetown, Sierra Leone, in 2012–2013. Interviews determined whether the participant disengaged or transferred care and explored the reasons for being LTFU. Of the 41 participants, 34 (83%) disengaged from care. For persons who disengaged from care, socioeconomic barriers emerged as a dominant theme in both ART-eligible and -ineligible groups while psychosocial barriers emerged as a dominant theme in the ART-ineligible group. Structural barriers emerged as a dominant theme for participants who transferred care. Interventions designed to address socioeconomic and psychosocial barriers may help reduce disengagement from pre-ART care.