Download TUAB033 – Integration Of Hiv And Non

Integration of HIV and Non-communicable
Disease management into Primary Care in
Nairobi, Kenya: Characteristics and Outcomes
Jeffrey K. Edwards1, Helen Bygrave2, Rafael Van den Bergh3, Walter Kizito1,
Erastus Cheti1, Rose J. Kosgei4, Agnès Sobry1, Alexandra Vandenbulcke1,
Shobha N. Vakil5, Tony Reid3
1 Médecins
Sans Frontières, Nairobi, Kenya
2 Médecins Sans Frontières, Southern Africa Medical Unit, Capetown, South
Africa
3 Médecins Sans Frontières, Operational Centre, Brussels, Belgium
4 Department of Obstetrics and Gynaecology, University of Nairobi, Nairobi,
Kenya
5 Kenya National AIDs and STI Control Program/HRH Capacity Bridge
Project, Nairobi, Kenya
BACKGROUND –
NON-COMMUNICABLE DISEASES



Non-communicable diseases (NCD) were declared a
neglected global health issue by WHO in 2005
Globally, the burden of NCD is increasing yearly
NCD health care needs remain unmet, especially in
resource-constrained settings such as Kibera:

need for well defined integrated models of primary care

lack of access to services

lack of adequately trained staff & NCD guidelines

medications remain expensive

follow up is a major challenge
BACKGROUND: MSF Context

The Kibera slum in Nairobi, Kenya, is characterized
by poverty, poor sanitation, and a highly mobile
population

Such populations are
vulnerable for NCD's,
such as hypertension
(HTN) and diabetes
mellitus (DM),
inaddition to HIV
BACKGROUND: NEW FOR MSF

In 2010, MSF integrated NCD care with the
existing HIV programme in three primary
health care clinics in the Kibera slum
DESCRIPTION –
PACKAGE OF CARE
The main components of the programme included:

A holistic team of health staff (clinical officers,
nurses, nutritionists, health educators, social
workers and adherence counsellors)

Offer of a package of care (clinical care, nutritional
and social support, and education on life style
measures, diseases and treatment)

Cohort outcome data monitoring
OBJECTIVE

To describe the characteristics and outcomes
of patients with NCDs (hypertension and/or
diabetes) with or without HIV

To assess whether the patients’ health can
be improved through an integrated model of
primary care
METHODS

Study site: three MSF-supported clinics in Kibera

Study period: January 2010-June 2013

Study population: all patients ≥ 15 years diagnosed with HTN
and/or DM:

HTN: BP (>140/90) measurements recorded during two or
more clinic visits

DM: fasting blood sugar ≥7.0 mmol/l

Routinely collected data extracted from a program database

Ethics clearance from Kenya Medical Research Institute and
MSF Ethics Review Board
RESULTS
Patient characteristics at enrolment into chronic disease cohort
Clinical
Characteristics
Male
Female
HIV+
HIV–
HIV+
HIV–
66 (10)
573 (90)
144 (9)
1423 (91)
Median age years
(IQR)
45 (39-53)
53 (46-60)
p<0.0001
43 (38-50)
47 (40-54)
p<0.001
BMI (kg/m2)
22 (20-24)
24 (20-26)
p=0.02
25 (22-28)
28 (24-32)
p<0.0001
Systolic BP (mm Hg,
IQR)
154 (137167)
160 (146178)
p=0.002
151 (136161)
160 (142177)
p<0.0001
Diastolic BP (mm Hg,
IQR)
97 (86-105)
99 (89-108)
97 (89-106)
Number patients
(%) n=2,206
100 (90-110)
p=0.006
RESULTS
Patient diagnosis at enrollment into chronic disease cohort
Male
Diagnosis
Female
HIV+
HIV–
HIV+
HIV–
Hypertension
(stages 1-3*)
61
477
p=0.004*
139
1220
p<0.001*
Diabetes
(type 1 & 2*)
5
96
5
203
p=0.008*
Chronic Kidney
Disease-concurrent
(CrCl < 60 ml/min)
7
94
23
142
RESULTS
Characteristics of people living with HIV in chronic disease cohort
Characteristic
Male (IQR)
Female (IQR)
Median age (years)
at HIV programme
enrollment
43 (36-50)
40 (34-46)
Median CD4 count at
NCD programme
enrollment
476 (339-578)
442 (305-554)
Median years in HIV
programme
4 (3-6)
5 (3-7)
Median years on ART
4 (3-6)
4 (2-6)
RESULTS
Chronic kidney disease within the cohort
 The frequency of chronic kidney disease (CKD = creatinine
clearance < 60 ml/min) in the combined cohort was 15%
(266/1802)
 There were no differences between the frequency of CKD in
people living with HIV (PLHIV) vs. those without HIV.
 Of those with CKD within the cohort, 15% (41/266) had
concurrent Type 1 or 2 diabetes mellitus.
 There was no association found between the use of tenofovir
and CKD among PLHIV.
 The median age for those with PLHIV and CKD was 47 (IQR 4154) vs. 59 (49-70) years without HIV (p < 0.0001).
RESULTS
Selected outcomes from the chronic disease program, 2010-2013
Male
Outcomes (median)
Systolic BP at last visit
HIV+ (IQR)
Female
HIV– (IQR)
HIV+ (IQR)
HIV– (IQR)
144 (133-155) 148 (131-161) 143 (129-157) 143 (126-156)
Diastolic BP at last visit
90 (79-97)
88 (80-96)
90 (81-98)
88 (79-96)
Last HbA1c in diabetics
9 (7-10)
9 (7-11)
8 (5-12)
9 (7-11)
Last total cholesterol in
diabetics
5 (5-6)
5 (4-6)
6 (5-7)
5 (4-6)
18/66 (27)
249/573 (44)
p=0.02
34/144 (24)
521/1423 (37)
p=0.002
Number lost to follow
up after 6 months or
longer (%)
LIMITATIONS

Short-term monitoring of 3.5 years: no
possibility to assess reduction in morbidity and
mortality

Poor documentation of complications at
baseline and during follow up
Strengths




This study provides a “real world” assessment
of an integrated primary care program from an
informal settlement
Standardized treatment protocols were used
for hypertension, diabetes, CKD and HIV that
were aligned with international guidelines
Program was primarily run by clinical officers
and nursing staff
Routine data monitoring was completed
CONCLUSIONS

This study highlights the need to recognize the
increasing chronic disease burden in sub-Saharan
Africa.

PLHA appear to be at higher risk of developing
concurrent NCDs at a younger age, and would benefit
from routine surveillance for them.

It is possible to integrate both HIV and NCD care
together in a primary care programme

This integrated programme can be run by clinical officers
and nursing staff within significant resource constraints.
ACKNOWLEDGEMENTS

A special thanks to the whole Kibera staff for their
work and dedication

This research was supported through the Médecins
Sans Frontières, Brussels-Luxembourg Operational
Research Unit

Médecins Sans Frontières-Operational Centre
Brussels brought technical support and
complementary programme funds
THANK YOU