Integration Of HIV And Non-communicable Disease (NCD) Services In Primary Care:

Comparison of Characteristics and Outcomes In People Living With HIV/AIDS and Those With

NCDs In Nairobi, Kenya

JK Edwards,1 H Bygrave,2 R Van den Bergh,3 W Kizito,1 E Cheti1 RJ Kosgei,4 A Sobry,1 A Vandenbulcke,1 T Reid3

1. Médecins Sans Frontières, Nairobi, Kenya. 2. Médecins Sans Frontières, London, UK. 3. Médecins Sans Frontières, Brussels, Belgium. 4. University of Nairobi, Nairobi, Kenya

AcknowledgementsThis project would not have been possible without the support of the Kibera project staff and reflects their on going tireless commitment to those who live within Kibera. This research was supported by the Operational Research Unit (LUXOR), Médecins Sans Frontières, Brussels Operational Centre, Luxembourg; the Centre for Operational Research, International Union Against Tuberculosis and Lung Disease (The Union), Paris, France and The Union South-East Asia Regional Office, Delhi, India.

MethodThis is a retrospective descriptive cohort study of routinely collected program data.

•  NCD healthcare package was developed using diagnostic and treatment protocols aligned with current international guidelines. •  Multidisciplinary clinical teams were trained on diagnosis and management of NCDs utilizing the protocols.

•  Patients ≥ 15 years old with or without HIV infection registered in the NCD clinic and managed for HTN and/or DM from January 2010 through June 2013.

•  Data were collected into a chronic disease collection tool.

•  NCD data were entered into an Epi Data database. •  PLWHA data were entered into a FUCHIA HIV database.

•  Statistical analysis was performed using the Epi Info 7 Analysis software package.

IntroductionWith the successful scale-up of antiretroviral therapy (ART) programmes, life expectancy of people living with HIV/AIDs (PLWHA) has increased and HIV is now considered a chronic disease.

Consequently, with increasing frequency populations are developing cardiovascular risk factors and comorbid diseases with HIV, such as hypertension, diabetes and kidney disease. However, little is known regarding the identification and management of chronic diseases in Africa, especially when associated with HIV.

Since 2010, Médecins Sans Frontières (MSF) has operated a primary care program in the Kibera slum caring for patients with NCDs. Using lessons learned from providing ART, NCDs and HIV/TB care were integrated in primary care clinics in Kibera. We describe cohort outcomes among PLWHA and without who have these NCDs.

ResultsKey findings on enrolment:

• 10% of males and 9% of females were PLWHA in NCD cohort

• male PLWHA patients were younger 45 vs 53 years (p < 0.0001)

• female PLWHA patients were younger 44 vs 47 years (p = 0.0006)

• female PLWHA patients had diabetes 4% (5/144) vs 14% (203/1423, p = 0.008)

• frequency of CKD (Cr Cl < 60 ml/min) was 14% (266/1802)

• frequency of CKD with diabetes was 15% (41/266)

• HIV negative males had CKD 20% (94/379) vs females 12% (142/1000, p = 0.0002)

• mean age of CKD for PWLHA was 47 vs 59 years (p < 0.0001)

• tenofovir was not associated with increased risk of CKD

Key outcome findings:

• Systolic/diastolic BP outcomes for males & females PLWHA or without:o male SBP PLWHA (mm Hg) 144 vs 148, female PLWHA 143 vs 143

o male DBP PLWHA (mm Hg) 90 vs 88), female PLWHA 90 vs 88

• Loss to follow up rates were lower in those with PLWHA vs without:o male PLWHA 27% (18/66) vs 44% (249/573, p = 0.02)

o female PLWHA 24% (34/144) vs 37% (521/1425, p = 0.002)

• 8 died during the study (5 HIV neg males, 2 HIV neg females, 1 PLWHA female)

ConclusionsThe frequency of PLWHA was similar to the prevalence in Kibera in the NCD cohort.

PLWHA were diagnosed younger with NCDs.

The frequency of CKD associated with DM was lower than in developed countries.

HIV negative males had a higher frequency of CKD.

The mean age of diagnosis for CKD was found to be 12 years earlier in those PWLHA.

Treatment outcomes for hypertension were similar.

PWLHA were less likely to be lost to follow up.

The lessons learnt from HIV treatment can be applied successfully to those with NCDs in low resource contexts.

Selected Characteristics Males Females

HIV + HIV - HIV + HIV -

Number of patients (%) 66 (10) 573 (90) 144 (9) 1423 (91)

Mean age years (IQR) 45 (39-53)p < 0.0001

53 (46-60) 44 (38-50)p = 0.0006

47 (40-54)

Systolic BP (mm Hg, IQR) 152 (137-167)p = 0.002

162 (146-178) 151 (136-161)p < 0.0001

160 (142-177)

Diastolic BP (mm Hg, IQR) 95 (86-105) 98 (89-108) 96 (89-106)p = 0.006

100 (90-110)

Patients by diagnosis Males (%) Females (%)

HIV + HIV - HIV + HIV -

Hypertension (stages 1-3) 61 (11) 477 (89) 139 (10) 1220 (90)

Diabetes (type 1 & 2) 5 (5) 96 (95) 5 (2) 203 (98)

Chronic kidney disease (CKD)

Cr Cl > 60 ml/min 53 (12) 379 (88) 104 (9) 1000 (91)

Cr Cl < 60 ml/min 7 (7) 94 (93) 23 (14) 142 (86)

Clinical characteristics of PLWHA Males (%) Females (%)

Mean age (years) at FUCHIA enrolment 42 (36-50) 40 (34-46)

WHO HIV stage at FUCHIA enrolment

Stage 1 6 (10) 19 (14)

Stage 2 24 (39) 60 (44)

Stage 3 25 (40) 46 (34)

Stage 4 7 (11) 11 (8)

Mean CD4 count 276 (104-370) 329 (236-488)

Mean years on antiretroviral treatment 4 4

Table 1. Characteristics of patients enrolled in NCD program, Kibera, Nairobi, Kenya

Table 2. Frequency of patients by presenting diagnosis, Kibera, Nairobi, Kenya

Table 3. Characteristics of PLWHA enrolled in NCD program, Kibera, Nairobi, Kenya