Paul O. Ayuo

Sustainability of first-line antiretroviral regimens: findings from a large HIV treatment program in western Kenya.

Objective:To describe first change or discontinuation in combination antiretroviral treatment (cART) among previously treatment naive, HIV-infected adults in a resource-constrained setting. Methods:The United States Agency for International Development-Academic Model Providing Access to Healthcare Partnership has enrolled >90,000 HIV-infected patients at 18 clinics throughout western Kenya. Patients in this analysis were aged ≥18 years, previously antiretroviral treatment naive, and initiated to cART between January 2006 and November 2007, with at least 1 follow-up visit. A treatment change or discontinuation was defined as change of regimen including single drug substitutions or a complete halting of cART. Results:There were 14,162 patients eligible for analysis and 10,313 person-years of follow-up, of whom 1376 changed or stopped their cART. Among these, 859 (62%) changed their regimen (including 514 patients who had a single drug substitution) and 517 (38%) completely discontinued cART. The overall incidence rate (IR) of cART changes or stops per 100 person-years was 13.3 [95% confidence interval (CI): 12.7-14.1]. The incidence was much higher in the first year of post-cART initiation (IR: 25.0, 95% CI: 23.6-26.3) compared with the second year (IR: 2.4, 95% CI: 2.0-2.8). The most commonly cited reason was toxicity (46%). In multivariate regression, individuals were more likely to discontinue cART if they were World Health Organization stage III/IV [adjusted hazard ratio (AHR): 1.37, 95% CI: 1.11-1.69] or were receiving a zidovudine-containing regimen (AHR: 4.44, 95% CI: 3.35-5.88). Individuals were more likely to change their regimen if they were aged ≥38 years (AHR: 1.44, 95% CI: 1.23-1.69), had to travel more than 1 hour to clinic (AHR: 1.34, 95% CI: 1.15-1.57), had a CD4 at cART initiation ≤111 cells/mm3 (AHR: 1.51, 95% CI: 1.29-1.77), or had been receiving a zidovudine-containing regimen (AHR: 3.73, 95% CI: 2.81-4.95). Those attending urban clinics and those receiving stavudine-containing regimens were less likely to experience either a discontinuation or a change of their cART. Conclusions:These data suggest a moderate incidence of cART changes and discontinuations among this large population of adults in western Kenya. Mostly occurring within 12 months of cART initiation, and primarily due to toxicity, older individuals, those with more advanced disease, and those using zidovudine are at higher risk of experiencing a change or a discontinuation in their cART.

HIV testing uptake and prevalence among adolescents and adults in a large home-based HIV testing program in Western Kenya.

Objective:To describe HIV testing uptake and prevalence among adolescents and adults in a home-based HIV counseling and testing program in western Kenya. Methods:Since 2007, the Academic Model Providing Access to Healthcare program has implemented home-based HIV counseling and testing on a large scale. All individuals aged ≥13 years were eligible for testing. Data from 5 of 8 catchments were included in this analysis. We used descriptive statistics and multivariate logistic regression to examine testing uptake and HIV prevalence among adolescents (13–18 years), younger adults (19–24 years), and older adults (≥25 years). Results:There were 154,463 individuals eligible for analyses as follows: 22% adolescents, 19% younger adults, and 59% older adults. Overall mean age was 32.8 years and 56% were female. HIV testing was high (96%) across the following 3 groups: 99% in adolescents, 98% in younger adults, and 94% in older adults (P < 0.001). HIV prevalence was higher (11.0%) among older adults compared with younger adults (4.8%) and adolescents (0.8%) (P < 0.001). Those who had ever previously tested for HIV were less likely to accept HIV testing (adjusted odds ratio: 0.06, 95% confidence interval: 0.05 to 0.07) but more likely to newly test HIV positive (adjusted odds ratio: 1.30, 95% confidence interval: 1.21 to 1.40). Age group differences were evident in the sociodemographic and socioeconomic factors associated with testing uptake and HIV prevalence, particularly, gender, relationship status, and HIV testing history. Conclusions:Sociodemographic and socioeconomic factors were independently associated with HIV testing and prevalence among the age groups. Community-based treatment and prevention strategies will need to consider these factors.

Frequency and factors associated with adherence to and completion of combination antiretroviral therapy for prevention of mother to child transmission in western Kenya

The objective of this analysis was to identify points of disruption within the prevention of mother‐to‐child transmission (PMTCT) continuum from combination antiretroviral therapy (CART) initiation until delivery.

Career choices and global health engagement: 24-year follow-up of U.S. participants in the Indiana University-Moi University elective

BACKGROUND Global health experiences evoke a profound awareness of cultural differences, inspire learners to prioritize professional values, and provide a lens for addressing global health care challenges. This study compares the long-term career and practice choices of participants in a 2-month Indiana University-Moi University, Kenya elective from 1989-2013 with those of a control group. METHODS Global health elective (GHE) participants and a random sample of alumni without GHE experience were surveyed on their clinical practice, public health and global health activities. RESULTS Responses from 176 former participants were compared with a control group of 177 alumni. GHE participants were more likely than similar controls to provide care to underserved U.S. populations (p=0.037), spend time in global health, public health, and public policy activities (p=0.005) and be involved in global health advocacy (p=0.001). Using multivariable analysis, GHE participants were more likely to be generalists (p<0.05), report that healthcare costs influenced medical decision-making (p<0.05), and provide healthcare outside the U.S. for ≥1 week/year (p<0.001). CONCLUSIONS Many years out of training, GHE participants were more likely to be generalists working with underserved populations, to be cost-conscious in their healthcare decision-making, and to be involved in global health, public health or public policy. IMPLICATIONS With the primary care provider shortage and need for greater awareness among providers of healthcare costs, our study shows that that global health experiences may yield broader benefits to the U.S. medical system.

Building Comprehensive and Sustainable Health Informatics Institutions in Developing Countries: Moi University Experience.

Current approaches for capacity building in Health Informatics (HI) in developing countries mostly focus on training, and often rely on support from foreign entities. In this paper, we describe a comprehensive and multidimensional capacity-building framework by Lansang & Dennis, and its application for HI capacity building as implemented in a higher-education institution in Kenya. This framework incorporates training, learning-by-doing, partnerships, and centers of excellence. At Moi University (Kenya), the training dimensions include an accredited Masters in HI Program, PhD in HI, and HI short courses. Learning-by-doing occurs through work within MOH facilities at the AMPATH care and treatment program serving 3 million people. Moi University has formed strategic HI partnerships with Regenstrief Institute, Inc. (USA), University of Bergen (Norway), and Makerere University (Uganda), among others. The University has also created an Institute of Biomedical Informatics to serve as an HI Center of Excellence in the region. This Institute has divisions in Training, Research, Service and Administration. The HI capacity-building approach by Moi provides a model for adoption by other institutions in resource-limited settings.