Samson Ndege

Evaluation of an Android-based mhealth system for population surveillance in developing countries

OBJECTIVE In parts of the developing world traditionally modeled healthcare systems do not adequately meet the needs of the populace. This can be due to imbalances in both supply and demand--there may be a lack of sufficient healthcare and the population most at need may be unable or unwilling to take advantage of it. Home-based care has emerged as a possible mechanism to bring healthcare to the populace in a cost-effective, useful manner. This study describes the development, implementation, and evaluation of a mobile device-based system to support such services. MATERIALS AND METHODS Mobile phones were utilized and a structured survey was implemented to be administered by community health workers using Open Data Kit. This system was used to support screening efforts for a population of two million persons in western Kenya. RESULTS Users of the system felt it was easy to use and facilitated their work. The system was also more cost effective than pen and paper alternatives. DISCUSSION This implementation is one of the largest applications of a system utilizing handheld devices for performing clinical care during home visits in a resource-constrained environment. Because the data were immediately available electronically, initial reports could be performed and important trends in data could thus be detected. This allowed adjustments to the programme to be made sooner than might have otherwise been possible. CONCLUSION A viable, cost-effective solution at scale has been developed and implemented for collecting electronic data during household visits in a resource-constrained setting.

What Is the Impact of Home-Based HIV Counseling and Testing on the Clinical Status of Newly Enrolled Adults in a Large HIV Care Program in Western Kenya?

BACKGROUND This article describes the effect point of entry into the human immunodeficiency virus (HIV) care program had on the clinical status of adults presenting for the first time to USAID-AMPATH (US Agency for International Development-Academic Model Providing Access to Healthcare) Partnership clinics for HIV care. METHODS All patients aged ≥ 14 years enrolled between August 2008 and April 2010 were included. Points of entry to USAID-AMPATH clinics were home-based counseling and testing (HBCT), provider-initiated testing and counseling (PITC), HIV testing in the tuberculosis clinic, and voluntary counseling and testing (VCT). Tests for trend were calculated, and multivariable logistic regression was used to compare the effect of HBCT versus other points of entry on primary outcomes controlling for age and sex. RESULTS There were 19,552 eligible individuals. Of these, 946 tested in HBCT, 10,261 in VCT, 8073 in PITC, and 272 in the tuberculosis clinic. The median (interquartile range) enrollment CD4 cell counts among those who tested HIV positive was 323 (194-491), 217 (87-404), 190 (70-371), and 136 cells/mm(3) (59-266) for HBCT, VCT, PITC, and the tuberculosis clinic, respectively (P < .001). Compared with those patients whose HIV infection was diagnosed in the tuberculosis clinic, those who tested positive in HBCT were, controlling for age and sex, less likely to have to have World Health Organization stage III or IV HIV infection at enrollment (adjusted odds ratio [AOR], 0.04; 95% confidence interval [CI], .03-.06), less likely to enroll with a CD4 cell count of <200 cells/mm(3) (AOR, 0.20; 95% CI, .14-.28), and less likely to enroll into care with a chief complaint (AOR, 0.08; 95% CI, .05-.12). CONCLUSIONS HBCT is effective at getting HIV-infected persons enrolled in HIV care before they become ill.

Linkage to and engagement in HIV care in western Kenya: an observational study using population-based estimates from home-based counselling and testing

BACKGROUND Few population-based studies exist on the HIV care continuum in sub-Saharan Africa. We aimed to describe engagement in care in all adults with an existing diagnosis of HIV and to assess the time to and predictors of linkage and engagement in adults newly diagnosed via home-based counselling and testing (HBCT) in a high-prevalence setting in western Kenya. METHODS Data were derived from AMPATH (Academic Model Providing Access to Healthcare), which has provided HIV care in western Kenya since 2001 and the HBCT programme, which has been operating since 2007. After a widespread HBCT programme in Bunyala subcounty from December, 2009, to February, 2011, we reviewed electronic medical records to identify uptake of care in individuals (aged 13 years or older) with previously known (self-reported) infection and new (identified at HBCT) HIV diagnoses as of June 1, 2014. We defined engagement in HIV care as an initial encounter with an HIV care provider. We used Cox regression analysis to examine the predictors of engagement in care for newly diagnosed individuals. FINDINGS Of the 3482 adults with HIV identified at HBCT, 2122 (61%) had previously been diagnosed with HIV, of whom 1778 (84%) had had at least one clinical encounter within AMPATH. 993 (73%) of the 1360 individuals with new diagnoses at HBCT were registered in the electronic medical records, although only 209 (15%) had seen a clinician over a median of 3·4 years since diagnosis. The median time to engagement in the newly diagnosed individuals was 60 days (IQR 10–411). INTERPRETATION Creative and innovative strategies are needed to support people to engage with care when they are newly diagnosed with HIV through population-based case-finding initiatives. FUNDING US President’s Emergency Plan for AIDS Relief (PEPFAR), Abbott Laboratories, the Purpleville Foundation, the Global Business Coalition, the US National Institute of Mental Health, and the Bill & Melinda Gates Foundation.

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.

Leapfrogging paper-based records using handheld technology: experience from Western Kenya.

PROBLEM There is limited experience with broad-based use of handheld technologies for clinical care during home visits in sub-Saharan Africa. OBJECTIVE We describe the design, development, implementation, and evaluation of a PDA/GPS-based system currently used during home visits in Western Kenya. RESULTS The system, built on Pendragon Forms, was used to create electronic health records for over 40,000 individuals over a three-month period. Of these, 1900 represented cases where the individual had never received care for the identified condition in an established care facility. On a five-point scale, and compared to paper-and-pen systems, end-users felt that the handheld system was faster (4.4±0.9), easier to use (4.5±0.8), and produced higher quality data (4.7±0.7). Projected over three years to cover two million people, use of the handheld technologies would cost about

Acceptance of HIV Testing for Children Ages 18 Months to 13 Years Identified Through Voluntary, Home-Based HIV Counseling and Testing in Western Kenya

0.15 per person--compared to

Quantifying the Impact of Accessibility on Preventive Healthcare in Sub-Saharan Africa Using Mobile Phone Data

0.21 per individual encounter entered manually into a computer from a paper form. CONCLUSION A PDA/GPS system has been successfully and broadly implemented to support clinical care during home-based visits in a resource-limited setting.

Delivery of HIV care during the 2007 post-election crisis in Kenya: a case study analyzing the response of the Academic Model Providing Access to Healthcare (AMPATH) program

Background:Home-based voluntary counseling and testing (HCT) presents a novel approach to early diagnosis. We sought to describe uptake of pediatric HIV testing, associated factors, and HIV prevalence among children offered HCT in Kenya. Methods:The USAID-Academic Model Providing Access to Healthcare Partnership conducted HCT in western Kenya in 2008. Children 18 months to 13 years were offered HCT if their mother was known to be dead, her living status was unknown, mother was HIV infected, or of unknown HIV status. This retrospective analysis describes the cohort of children encountered and tested. Results:HCT was offered to 2289 children and accepted for 1294 (57%). Children were more likely to be tested if more information was available about a suspected or confirmed maternal HIV infection [for HIV-infected living mothers odds ratio (OR) = 3.20, 95% confidence interval (CI): 1.64 to 6.23), if parents were not in household (OR = 1.50, 95% CI: 1.40 to 1.63), if they were grandchildren of head of household (OR = 4.02, 95% CI: 3.06 to 5.28), or if their father was not in household (OR = 1.41, 95% CI: 1.24 to 1.56). Of the eligible children tested, 60 (4.6%) were HIV infected. Conclusions:HCT provides an opportunity to identify HIV among high-risk children; however, acceptance of HCT for children was limited. Further investigation is needed to identify and overcome barriers to testing uptake.

Health facility barriers to HIV linkage and retention in Western Kenya

Background: Poor physical access to health facilities has been identified as an important contributor to reduced uptake of preventive health services and is likely to be most critical in low-income settings. However, the relation among physical access, travel behavior, and the uptake of healthcare is difficult to quantify. Methods: Using anonymized mobile phone data from 2008 to 2009, we analyze individual and spatially aggregated travel patterns of 14,816,521 subscribers across Kenya and compare these measures to (1) estimated travel times to health facilities and (2) data on the uptake of 2 preventive healthcare interventions in an area of western Kenya: childhood immunizations and antenatal care. Results: We document that long travel times to health facilities are strongly correlated with increased mobility in geographically isolated areas. Furthermore, we found that in areas with equal physical access to healthcare, mobile phone-derived measures of mobility predict which regions are lacking preventive care. Conclusions: Routinely collected mobile phone data provide a simple and low-cost approach to mapping the uptake of preventive healthcare in low-income settings.

Effects of HIV-1 infection on malaria parasitemia in milo sub-location, western Kenya

BackgroundWidespread violence followed the 2007 presidential elections in Kenya resulting in the deaths of a reported 1,133 people and the displacement of approximately 660,000 others. At the time of the crisis the United States Agency for International Development-Academic Model Providing Access to Healthcare (USAID-AMPATH) Partnership was operating 17 primary HIV clinics in western Kenya and treating 59,437 HIV positive patients (23,437 on antiretroviral therapy (ART)).MethodsThis case study examines AMPATH’s provision of care and maintenance of patients on ART throughout the period of disruption. This was accomplished by implementing immediate interventions including rapid information dissemination through the media, emergency hotlines and community liaisons; organization of a Crisis Response leadership team; the prompt assembly of multidisciplinary teams to address patient care, including psychological support staff (in clinics and in camps for internally displaced persons (IDP)); and the use of the AMPATH Medical Records System to identify patients on ART who had missed clinic appointments.ResultsThese interventions resulted in the opening of all AMPATH clinics within five days of their scheduled post-holiday opening dates, 23,949 patient visits in January 2008 (23,259 previously scheduled), uninterrupted availability of antiretrovirals at all clinics, treatment of 1,420 HIV patients in IDP camps, distribution of basic provisions, mobilization of outreach services to locate missing AMPATH patients and delivery of psychosocial support to 300 staff members and 632 patients in IDP camps.ConclusionKey lessons learned in maintaining the delivery of HIV care in a crisis situation include the importance of advance planning to develop programs that can function during a crisis, an emphasis on a rapid programmatic response, the ability of clinics to function autonomously, patient knowledge of their disease, the use of community and patient networks, addressing staff needs and developing effective patient tracking systems.