INTEGRATING PREVENTION INTO HIV CARE AND TREATMENTKENYA’S PROGRESS AND PLANS

DR. EMILY KOECH-KETERDIRECTOR OF PROGRAMSICAP, KENYA

Kenya HIV statistics

• HIV prevalence 7.4% (KAIS 2007); 1.4 million HIV-infected people

• 500,000 people enrolled in HIV care

• 213,000 people on antiretroviral therapy (June 2008)

• 500 facilities offering HIV care– 80% are public health

facilities

Why Prevention with Positives (PwP) Kenya statistics

• 45% of married HIV-infected persons, have HIV uninfected partner (KAIS 2007 )

• Low rates of consistent condom use

• 80% of HIV-infected do not have correct knowledge of their HIV status (KAIS 2007 )

• High rates of STI in populations in Sub-Saharan African countries; 81% of HIV-infected Kenyan adults have genital herpes (KAIS 2007 )

• Increased sexual activity and unprotected sex among HIV-infected people once they are on ART (Bunnell CROI 2008)

Advancing Policy and Guidelines

• NASCOP-led PWP technical working group (TWG) established:– MOH, TB and Reproductive health programs– WHO, UNAIDS, CDC, USAID, – Implementing partners, FBO, etc

• TWG functions:– Spearhead development and implementation of

national PWP policies and guidelines, training and implementation materials, M & E tools and roll-out plan

– Oversee coordination of PwP activities at clinical and community levels

Development of Training Curriculum

• 2006-2007, PEPFAR/CDC developed and piloted PWP materials for clinical settings in 3 different sites in Kenya– MOH and partners reviewed and adapted materials

(flipcharts, pocket cards, posters, handouts)– Materials translated into Swahili and printed

• June 2008 PwP Training of Trainers (TOT)s conducted – TOTs were health care workers from TB and HIV

programs selected by MOH and implementing care and treatment partners

– Represented 10 regions• ICAP to contribute to further TOTs and local trainings

PWP Clinic Materials

Materials stress 5 steps: disclosure, partner testing, condom use, STI diagnosis/treatment, and FP

National Planned activities

• A detailed roll out plan, including regional sensitization meetings planned

• Two PwP TOTs held; These trainers will roll-out regional trainings

• Plans to develop a package that will clearly outline community-based PwP activities.

• PEPFAR evaluation to examine a comprehensive PWP approach in clinical settings to start in Central Province in 2008-2009

PwP implementation challenges

• Human resources– Inadequate staffing, increased work load, low

retention, frequent transfers– Inadequate training to address prevention issues

• Limited physical infrastructure - privacy

• Ensuring commodity security – (condoms, FP methods, STI drugs)

• Creating parallel services – (HIV care, STI services and reproductive health

• Documentation

International Centres for AIDS Care and Treatment Programs (ICAP), Kenya

• In Kenya, ICAP supports HIV care and ART in Central and Eastern Provinces:– 73 health care facilities– 46,468 people in care– 20,176 on ART

Current Prevention activities in HIV clinics-I

• ART adherence emphasized during routine counseling• Condoms provided at HIV clinics• STI treatment available for symptomatic patients• FP counseling and services available on request• Currently working on strengthening partner testing • Training and use of Peer educators to deliver basic HIV

services, counseling, sharing experiences

• However integration of PwP activities in many of the clinics has been weak, difficult, not comprehensive and not standardized or routinely performed.

Current Prevention activities in HIV clinics-II

• Partner testing- piloting of family HIV status forms to prompt patients to bring partners and children for testing. The results indicated:– Increased number of children brought for testing– Increased request by patients for counseling on how

to disclose – Perceived by health care workers to be time

consuming and leading to increased work load– HIV testing often by referral of patients to VCT which

leads to patient loss. Trying to move partner testing to HIV clinic

ICAP’s role at National level

• Members of the PwP technical working group– Currently working with NASCOP in the integration of FP/STI

component

• Some ICAP staff are trained as facilitators for PwP and will be involved in regional trainings.

• ICAP will conduct Regional TOT trainings in 6 regions. Those trained will subsequently facilitate PwP trainings within the region.

• PwP intervention are being carried out in ICAP supported facilities and the outcome will inform national role out.

PwP PHE Objectives

• To evaluate efficacy of HIV prevention interventions integrated into routine care and treatment of HIV patients in clinics in resource-limited settings

• To assess feasibility/acceptability of integrating prevention interventions into routine care and treatment of HIV patients

Study Design

• 12-month group randomized trial in 3 countries, Kenya, Tanzania and Namibia

• 6 clinics per country; matched pairs of 3 intervention and 3 control– Clinics matched on patient load, health care provider,

clinic space– Train providers in intervention sites to deliver

interventions; standard of care given to control sites– 200 patients enrolled per site (care only and ART)

Interventions

• Provider delivered prevention messages– Reducing risky sexual behaviour– Condom use– HIV status disclosure– Partner HIV testing

• ART medication adherence• STI assessment and treatment• FP counseling and services• Alcohol reduction

*Lay counsellors will be trained and used to counsel patients on these issues.

Standards of care

• Cotrimoxazole prophylaxis• Multivitamin supplementation• ARV if eligible• Adherence counseling • OI diagnosis and management• Laboratory monitoring

*STI/FP services, counseling on disclosure, partner testing are not provided routinely

Outcome Measures

• Behavioural:– Risky sexual behaviour– HIV testing of partners– Disclosure– Alcohol use– ARV medication adherence

• Biologic– STI symptoms– Unintended pregnancies

• Service delivery– Treatment of STI– FP counseling and services

Progress on the PHE

• Study coordinator recruited and trained • Initial pilot site identified

– HIV clinic staff trained to deliver HIV prevention messages and STI services

– Supportive supervision provided by study coordinator– Interviews to be held with the implementing staff on

the 11-12 Aug, to gather information on their experiences with implementation

– Information gathered will help assess feasibility of the expansion of the study

Acknowledgments

• Ministry of Health, NASCOP• CDC• USAID/APHIA II• WRP/DoD• Provincial Medical Office• DMOH and MOH hospitals• Hospital Management Teams• Implementing partners