Rakhi Karwa

The Evolution of Diabetes Care in the Rural, Resource-Constrained Setting of Western Kenya

BACKGROUND: The initial focused effort on addressing the HIV pandemic in ***sub-Saharan Africa has helped set the groundwork for addressing many of the other areas of the health-care system requiring support in resource-constrained settings. With the growing prevalence of diabetes in this setting, the US Agency for International Development—Academic Model Providing Access to Healthcare Partnership (USAID-AMPATH) has begun developing infrastructure to meet the growing need for diabetes care. OBJECTIVE: To describe the evolution of diabetes care in the rural, resource-constrained setting of western Kenya and to analyze preliminary data on the current status of glucose control of patients. METHODS: Through partnerships, USAID-AMPATH has facilitated the provision of basic modalities of diabetes care, including reliable stocks of insulin, hemoglobin A1c (A1C) testing, and point-of-care glucose-testing supplies. RESULTS: Through the introduction of A1C testing, the poor quality of diabetes care was revealed, as the average A1C for the clinic population was 10.4%, with insulin-dependent patients constituting the majority of individuals with markedly elevated A1C levels. To address this, a contextualized electronic medical record and a cell phone-based home glucose monitoring program were created to improve glycemic control, which has led to significant reductions in A1C levels. CONCLUSIONS: Through the inclusion of clinical data within the electronic medical record, there is an ongoing effort to research various aspects of diabetes care in this understudied population, with the goal of addressing many of the unanswered questions surrounding diabetes care in sub-Saharan Africa. The lessons learned from this pilot program will be used to create sustainable infrastructure for diabetes care in partnership with the Kenyan government and will serve as a model for similar programs.

Performance outcomes of a pharmacist-managed anticoagulation clinic in the rural, resource-constrained setting of Eldoret, Kenya

Summary.  Background: It is recommended that warfarin therapy should be managed through an anticoagulation monitoring service to minimize the risk of bleeding and subsequent thromboembolic events. There are few studies in Sub‐Saharan Africa that describe warfarin management in spite of the high incidence of venous thromboembolism (VTE) and rheumatic heart disease. Objective: To examine the feasibility of the Moi Teaching and Referral Hospital anticoagulation monitoring service and compare its performance with clinics in resource‐rich settings. Methods: A retrospective chart review compared the percentage time in the therapeutic range (TTR) and rates of bleeding and thromboembolic events to published performance targets using the inference on proportions test. Wilcoxon’s rank sum analyses were used to establish predictors of TTR. Results: For the 178 patients enrolled, the mean TTR was 64.6% whereas the rates of major bleeds and thromboembolic events per year were 1.25% and 5%, respectively. In the primary analysis, no statistically significant differences were found between the results of TTR, major bleeds and thromboembolic events for the clinic and published performance rates. In the secondary analysis, having an artificial heart valve and a duration of follow‐up of > 120 days were positively associated with a higher TTR (P < 0.05) whereas venous thromboembolism, history of tuberculosis, HIV and a duration of follow‐up of < 120 days were associated with having a lower TTR (P < 0.05). Conclusions: The performance of the MTRH anticoagulation clinic is non‐inferior to published metrics on the performance of clinics in resource‐rich settings.

Meeting the Needs of Underserved Patients in Western Kenya by Creating the Next Generation of Global Health Pharmacists

Objective. To describe a novel training model used to create a sustainable public health-focused pharmacy residency based in Kenya and to describe the outcomes of this training program on underserved populations. Design. The postgraduate year 2 residency was designed to expose trainees to the unique public health facets of inpatient, outpatient, and community-based care delivery in low and middle-income countries. Public health areas of focus included supply chain management, reproductive health, pediatrics, HIV, chronic disease management, and teaching. Assessment. The outcomes of the residency were assessed based on the number of new clinical programs developed by residents, articles and abstracts written by residents, and resident participation in grant writing. To date, six residents from the United States and eight Kenyan residents have completed the residency. Eleven sustainable patient care services have been implemented as a result of the residency program. Conclusion. This pharmacy residency training model developed accomplished pharmacists in public health pharmacy, with each residency class expanding funding and clinical programming, contributing to curriculum development, and creating jobs.

Leveraging peer-based support to facilitate HIV care in Kenya

Rakhi Karwa and colleagues discuss a program in which peer navigators support care for people with HIV at a Kenyan hospital.

Randomized controlled trial to evaluate locally sourced two-component compression bandages for HIV-associated Kaposi sarcoma leg lymphedema in western Kenya: The Kenyan Improvised Compression for Kaposi Sarcoma (KICKS) study protocol

Background HIV-associated Kaposi sarcoma (KS), among the most frequent cancers seen in sub-Saharan Africa, is associated with a high prevalence of lymphedema. Lymphedema causes progressive functional impairment marked by swelling, physical discomfort, disfiguring changes, skin hardening from fibrosis, poor wound healing, and recurrent skin infection. While compression therapy is considered a major component of lymphedema management, this intervention has never been evaluated in HIV-associated KS lymphedema. Methods/design The Kenyan Improvised Compression for Kaposi Sarcoma (KICKS) study is a randomized, controlled trial. Due to variable lymphedema stage, we will use block randomization with a 1:1 allocation to assign participants to one of two groups: “Immediate compression” or “Delayed compression.” Those randomized to “Immediate compression” intervention arm will receive weekly two-component compression bandages while receiving chemotherapy, whereas those in the “Delayed compression” control arm will be followed during chemotherapy and then receive compression after chemotherapy is completed. The primary outcome is change in Lower Extremity Lymphedema Index from enrollment at Week 0 to blinded outcome assessment at Week 14 between intervention and control arms. Secondary outcomes are change in leg lymphedema-specific quality of life (LYMQOL) and change in overall health quality of life in cancer (EORTC QLQ C30). Discussion This represents the first study in sub-Saharan Africa to assess a lymphedema-directed intervention for KS, and the intervention—locally sourced two-component compression bandages—is affordable and available. Thus, the KICKS study is an important step towards developing an evidence-based path for regionally relevant management of HIV-associated KS lymphedema. Trial registration This trial was registered at ClinicalTrials.gov on January 19, 2018: identifier NCT03404297.

Infective Endocarditis in Low- and Middle-Income Countries

Infective endocarditis (IE) is a rare, life-threatening disease with a mortality rate of 25% and significant debilitating morbidities. Although much has been reported on contemporary IE in high-income countries, conclusions on the state of IE in low- and middle-income countries (LMICs) are based on studies conducted before the year 2000. Furthermore, unique challenges in the diagnosis and management of IE persist in LMICs. This article reviews IE studies conducted in LMICs documenting clinical experiences from the year 2000 to 2016. Presented are the causes of IE, management of patients with IE, and prevailing challenges in diagnosis and treatment of IE in LMICs.

Venous Thromboembolism Requiring Extended Anticoagulation Among HIV-Infected Patients in a Rural, Resource-Constrained Setting in Western Kenya.

Background: HIV-infected patients are at an increased risk of developing venous thromboembolism (VTE), and minimal data are available to describe the need for extended treatment. Objective: To evaluate the frequency of and determine predictive risk factors for extended anticoagulation of VTE in HIV-infected patients in rural, western Kenya. Methods: A retrospective chart review was conducted at the Anticoagulation Monitoring Service affiliated with Moi Teaching and Referral Hospital and the Academic Model Providing Access to Healthcare. Data were collected on patients who were HIV-infected and receiving anticoagulation for lower-limb deep vein thrombosis. The need for extended anticoagulation, defined as receiving ≥7 months of warfarin therapy, was established based on patient symptoms or Doppler ultrasound–confirmed diagnosis. Evaluation of the secondary outcomes utilized a univariate analysis to identify risk factors associated with extended anticoagulation. Results: A total of 71 patients were included in the analysis; 27 patients (38%) required extended anticoagulation. The univariate analysis showed a statistically significant association between the need for extended anticoagulation and achieving a therapeutic international normalized ratio within 21 days in both the unadjusted and adjusted analysis. Patients with a history of opportunistic infections required an extended duration of anticoagulation in the adjusted analysis: odds ratio = 3.42; 95% CI = 1.04-11.32; P = 0.04. Conclusions: This study shows that there may be a need for increased duration of anticoagulation in HIV-infected patients, with a need to address the issue of long-term management. Guideline recommendations are needed to address the complexity of treatment issues in this population.

Learning to Sew: A Student Pharmacist’s Service-Learning Experience

The collaboration between Purdue University College of Pharmacy and the USAID—AMPATH partnership gives student pharmacists the opportunity to complete an internal medicine experience in Eldoret, Kenya. Student pharmacists act as the pharmaceutical resource on multidisciplinary teams at Moi Teaching and Referral Hospital (MTRH). Adding to the experience, the sewing initiative is one of numerous service-learning opportunities that have evolved in this resource-constrained setting. The initiative takes place at the Sally Test Pediatric Center, a place for children to learn and play while in the hospital. The program teaches sewing, an income-generating skill, to parents of hospitalized children. Students assist with sewing lessons, provide health care education for parents, and care for children while their parents learn a skill that can potentially provide a sustainable income. This program aids student pharmacists in balancing service and learning while working in a resource-constrained setting. This article describes the implementation of the sewing initiative, the goals of the project, the participants and students, and the initial impact. Karolina M. Grzesiak; Craig A. Vargo, PharmD, BCOP; Ellen M. Schellhase, PharmD; Monica L. Miller, PharmD, MS; Rakhi Karwa, PharmD, BCPS; Sonak D. Pastakia, PharmD, MPh, BCPS; and Beatrice Jakait, BPharm, PharmD