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, Kenya2 Médecins Sans Frontières, Southern Africa Medical Unit, Capetown, South Africa3 Médecins Sans Frontières, Operational Centre, Brussels, Belgium 4 Department of Obstetrics and Gynaecology, University of Nairobi, Nairobi, Kenya5 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

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

DESCRIPTION –PACKAGE OF CARE

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

OBJECTIVE

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

METHODS

RESULTSPatient characteristics at enrolment into chronic disease cohort

Clinical Characteristics Male Female

HIV+ HIV– HIV+ HIV–

Number patients(%) n=2,206

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 (137-167)

160 (146-178)

p=0.002

151 (136-161)

160 (142-177)

p<0.0001

Diastolic BP (mm Hg, IQR)

97 (86-105) 99 (89-108) 97 (89-106)100 (90-110)

p=0.006

RESULTSPatient diagnosis at enrollment into chronic disease cohort

Diagnosis Male Female

HIV+ HIV– HIV+ HIV–

Hypertension(stages 1-3*)

61 477p=0.004*

139 1220p<0.001*

Diabetes(type 1 & 2*)

5 96 5 203p=0.008*

Chronic Kidney Disease-concurrent(CrCl < 60 ml/min)

7 94 23 142

RESULTSCharacteristics 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)

RESULTSChronic 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 41-54) vs. 59 (49-70) years without HIV (p < 0.0001).

RESULTSSelected outcomes from the chronic disease program, 2010-2013

Male Female

Outcomes (median) HIV+ (IQR) HIV– (IQR) HIV+ (IQR) HIV– (IQR)

Systolic BP at last visit 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)

Number lost to follow up after 6 months or longer (%)

18/66 (27)  

249/573 (44)p=0.02

34/144 (24)  

521/1423 (37)p=0.002

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

LIMITATIONS

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

Strengths

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.

CONCLUSIONS

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

ACKNOWLEDGEMENTS

THANK YOU