Nurse-led HIV services and quality of care at health facilities in Kenya, 2014–2016
Miriam Rabkin a, Matthew Lamb a, Zainab T Osakwe a, Peter R Mwangi b, Wafaa M El-Sadr a & Susan Michaels-Strasser a
a. International Center for AIDS Care and Treatment Programs (ICAP) at Columbia University, 722 West 168th Street, New York, NY 10032, United States of America.
b. ICAP at Columbia University, Nairobi, Kenya.
Correspondence to Miriam Rabkin (email: firstname.lastname@example.org).
(Submitted: 15 June 2016 – Revised version received: 27 December 2016 – Accepted: 18 January 2017 – Published online: 05 April 2017.)
Bulletin of the World Health Organization 2017;95:353-361. doi: http://dx.doi.org/10.2471/BLT.16.180646
The global response to the human immunodeficiency virus (HIV) epidemic has been remarkably successful. In low- and middle-income countries, the number of people living with HIV who have access to antiretroviral treatment (ART) rose from 400 000 in 2003 to 17 million in 2015. Modelling estimates from the Joint United Nations Programme on HIV/AIDS (UNAIDS) suggest that annual deaths from the acquired immunodeficiency syndrome (AIDS) have dropped by 43% over the same period1 and 7.8 million deaths have been averted by the scale-up of ART services.2 Increased access to prevention and treatment has also led to an estimated 35% drop in new HIV infections since 2000, including a 58% decrease among children.3
Despite these achievements, UNAIDS modelling highlights that only 46% of people living with HIV have initiated ART and 2.1 million new HIV infections occurred in 2015.1 Scaling up HIV prevention and treatment services and ensuring their quality is important if the ambitious global goals are to be met.4 The 2020 UNAIDS 90–90–90 targets call for 90% of people living with HIV to be aware of their HIV status, 90% of those diagnosed with HIV to be on ART and 90% of those on ART to achieve viral suppression.5 To reach these targets, people living with HIV need to learn their HIV status, link to appropriate treatment, achieve virological suppression and remain in care and on treatment for their lifetime. Careful attention to each step along the treatment continuum is essential,6 as sustained retention in care remains a challenge in many HIV programmes.7
HIV programme quality is assessed via diverse process indicators in both low- and high-resource settings.8 For example, the Site Improvement through Monitoring System approach used by the United States President’s Emergency Plan for AIDS Relief (PEPFAR) assesses core essential elements for quality service delivery at the community, clinic (site) and above-site levels. HIV programme quality is often also assessed by examining outcomes along the continuum of HIV care, including: the proportion of patients testing positive for HIV who are linked to care; the proportion started on treatment; the proportion who remain in care; and the proportion who achieve viral suppression (in settings where viral load measurement is available). Because this approach only includes patients eligible for ART, more inclusive measures of the continuum of HIV care have been proposed that capture outcomes for all HIV-infected individuals enrolled in care.9
We used a novel and comprehensive measure of comprehensive retention in HIV care to characterize programme quality at health facilities in Kenya, and explored the associations with patient- and facility-level characteristics.
Study design and setting
We conducted an observational, longitudinal analysis using routinely collected clinical information on 13 331 HIV-infected individuals enrolled at 63 health facilities in the Eastern and Nyanza regions of Kenya. Health facility staff provided clinical services according to Kenya’s national guidelines.10 All facilities were receiving technical assistance from the International Center for AIDS Care and Treatment Programs (ICAP) at Columbia University via funding from PEPFAR; this included in-service training using Kenya’s national training curricula, supportive supervision, and mentoring on routine data collection and analysis. For this analysis, we assessed the relationship between selected patient and facility parameters and the outcome indicator: comprehensive retention in HIV care.
The Optimal Models of HIV care project is a multi-country project, funded by the Centers for Disease Control and Prevention, aimed at improving the use of routinely-collected HIV care and treatment data for programme monitoring, evaluation, operations research and implementation science. As part of this project, we collect de-identified patient-level data from ICAP-supported health facilities in Ethiopia, Kenya, Mozambique, Rwanda and the United Republic of Tanzania. Details of the methods are described elsewhere.11 Briefly, at each patient visit, clinic staff document routinely collected patient information on national forms. This information is regularly entered into electronic databases by data clerks, with data quality assessments performed at least annually at each clinic. This analysis focused on Kenya, chosen because of the variability in nurse-led ART services in the country and to restrict between-country variability as an explanation for any findings. Data were collected on patients enrolling in HIV care between 1 January 2014 and 31 March 2015. Information on follow-up visits was included up to 31 March 2016.
Patient-level covariates included age (categorized into < 2 years, 2–14 years, 15–24 years, 25–39 years, 40–49 years and ≥ 50 years), sex and HIV disease stage at enrolment. Disease stage was categorized into: CD4+ T lymphocyte (CD4+ cell) count < 200 cells/µL, or WHO stage 3 or 4;12 CD4+ cell count > 200 cells/µL, or WHO stage 1 or 2; or missing data on both CD4+ cell and WHO staging.
ICAP staff collected facility-level characteristics in August 2015 using ICAP’s Program and Facilities Characteristics Tracking System site checklist. This is a biannual site assessment of the HIV care and treatment services and staffing at health facilities supported by ICAP.
Facility-level factors included: facility type (public primary, public secondary or private); setting (urban, semi-urban or rural); availability of on-site CD4+ cell testing; patient volume (categorized based on number of new enrollees into HIV care per year); availability of specific services (community ART adherence groups; financial incentives for adherence; facility-based group counselling for adherence support); and types of health-care worker at the facility (physicians, nurses, clinical officers [non-physician clinicians] or outreach workers). In addition, the survey assessed the availability of nurse-led ART services (assessment of eligibility for ART; initial prescriptions for ART; and follow-up care for ART).
The primary outcome of interest in this analysis was a comprehensive measure combining retention in HIV care for 12 months and receipt of key services during that time. The comprehensive retention indicator included variables relevant to patients who were eligible for ART as well as those who were not yet eligible for ART; all patients received clinical and immunological monitoring, prophylaxis for opportunistic infections and counselling.
Patients who started ART within 12 months of enrolment met the definition of comprehensive retention in HIV care if they were assessed for ART eligibility; initiated on ART or retained in care until becoming eligible for ART (based on country guidelines),10 and retained on ART for 12 months after enrolment at the health facility. Patients also met the definition of comprehensive retention in care if they were assessed for ART eligibility; found to be ineligible based on country guidelines; and retained in care at the health facility for 12 months after enrolment. Evidence of assessment for eligibility was a record of CD4+ cell count or World Health Organization (WHO) HIV/AIDS clinical stage12 before ART initiation.
Patients did not meet the definition of comprehensive retention if they were missing a recorded WHO stage or CD4+ cell count in their medical records; designated as ART-eligible (according to CD4+ cell count or WHO stage); and did not initiate ART. Patients not in comprehensive retention also included those who died or became lost to follow-up in the 12 months after enrolment.
For all analyses, patients were considered lost to follow-up if they had no recorded visit in the last 3 months (patients on ART) or 6 months (patients not on ART).
Descriptive statistics were used to describe the demographic and clinical characteristics of the study population. In analyses investigating factors associated with achievement of retention in care at 12 months (as defined above), univariate analyses were conducted using generalized linear mixed log-binomial regression models with random intercepts to account for within-clinic correlation. Outcomes are presented as the relative risk (RR) and 95% confidence interval (CI) of achieving 12-month retention in HIV care.
For the multivariable analyses, two models were examined. The first model included only facility-level covariates, while the second model included facility-level and patient-level covariates. For models 1 and 2, facility type was included because it was a priori identified as a potential confounder of the relationship between the availability of nurse-led initiation/management of ART and retention at 12 months. Other facility-level covariates found significant at α < 0.05 in the univariate analysis were also included in the multivariable models. The three measures focusing on nurse-led initiation and management of ART (i.e. assessment of ART eligibility by nurse; initiation of ART by nurse; and follow-up of ART by nurse) were highly collinear with each other; therefore only one (initiation of ART by nurse) was included in the multivariable models. The latter was selected because it had the strongest association with our outcome of interest in the univariate analysis. In model 2, patient-level covariates included age, sex and disease stage at enrolment in care.
Use of anonymized patient-level data from health facilities was conducted as part of the Identifying Optimal Models of HIV Care and Treatment study. All data were de-identified before analysis and the investigators had no access to identifiable patient information. Institutional review board approval was obtained from the ethical review board in Kenya; the study was designated non-human subjects research by the institutional review board at Columbia University Medical Center and the Center for Global Health at the United States Centers for Disease Control and Prevention.
Table 1 presents the facility-level and patient-level characteristics of the population. The majority of facilities in this study were public primary health-care centres (33 facilities, 52%), treating 5856 (44%) patients. Nearly all facilities were situated in urban or semi-urban settings. CD4+ cell testing was performed on-site in 18 facilities (29%) where 5661 patients were enrolled (42% of the patient population). For the remaining facilities and patients, blood drawn at the facility was transported off-site for CD4+ cell testing. Community ART adherence groups were available at 32 facilities (51%), financial incentives for ART adherence at 5 facilities (8%) and group counselling at 61 facilities (97%). At 5 facilities (8%) of physicians were available in addition to nurses and other health-care workers, providing care to 1436 patients (11%); other facilities were staffed only by nurses and clinical officers. Outreach workers were available at 29 facilities (46%). Most patients were enrolled at facilities where nurses assessed patients for ART eligibility (11 996, 90%), initiated ART prescriptions (11 092, 83%) and gave follow-up care to patients on ART (10 738, 81%).
Table 1. Characteristics of facilities and patients in the study of quality of HIV care at health facilities in the Eastern and Nyanza regions of Kenya, January 2014 to March 2016
Of the patient-level characteristics investigated, median age at enrolment was 30.2 years (interquartile range, IQR: 23.7–38.5), and 8603 (65%) patients were female. At enrolment in HIV care, 7847 patients (59%) had a CD4+ cell count > 200 cells/µL, or WHO stage 1 or 2; 3612 (27%) had a CD4+ cell count < 200 cells/µL, or WHO stage 3 or 4; and 1872 (14%) were missing both CD4+ cell count and WHO stage. Of those with unrecorded immune status at enrolment, 36 (2%) were recorded as dead at 12 months, compared with 80 (1%) among those with a CD4+ cell count > 200 cells/µL, or WHO stage 1 or 2, and 136 (4%) among those with a CD4+ cell count ≤ 200 cells/µL, or WHO stage 3 or 4.
Table 2 shows the results of univariate analyses, presenting the relative risk of retention in comprehensive HIV care for 12 months after enrolment. Of the 13 331 patients in the study sample, 8404 (63%) achieved comprehensive retention in care. Of the 4927 (37%) not achieving comprehensive retention, 208 (4%) died within 12 months, 629 (13%) never had their ART eligibility assessed, 381 (8%) were ART-eligible but did not initiate therapy and 3709 (75%) were lost to follow-up.
Table 2. Univariate analyses of comprehensive retention in care among 13 331 HIV-positive patients enrolled in care at 63 facilities in the Eastern and Nyanza regions of Kenya, January 2014 to March 2016
Retention in comprehensive HIV care for 12 months was significantly more likely at facilities where nurses assessed patients for eligibility and initiated and followed-up patients on ART. For example, 66% (7318/11 092) of patients enrolled at facilities where nurses initiated ART were retained in comprehensive care for 12 months, compared with 49% (1086/2239) of patients at facilities where nurses did not initiate therapy (RR: 1.30; 95% CI: 1.06–1.60). In contrast, patients at facilities with a physician were less likely to achieve 12-month retention than those at facilities without a physician (RR: 0.75; 95% CI: 0.57–0.98). In addition, patients at facilities with the smallest new patient enrolment had significantly lower 12-month retention in comprehensive care (RR: 0.78; 95% CI: 0.65–0.93) compared with sites with the medium level of enrolment. Lastly, 12-month retention was significantly lower among patients with more advanced HIV disease (RR: 0.75; 95% CI: 0.73–0.78) and those missing CD4+ cell count or WHO staging (RR: 0.67; 95% CI: 0.64–0.71).
Table 3 shows the findings based on multivariate analyses. In model 1 (adjusting only for facility-level characteristics), patients at facilities where nurses initiated ART were significantly more likely to be retained in care for 12 months (RR: 1.25; 95% CI: 1.01–1.54). No other facility-level characteristics remained statistically significant in this model. In model 2, in which we adjusted for both facility- and patient-level characteristics, 12-month retention was more likely for patients attending facilities with nurse-initiated ART (RR: 1.22; 95% CI : 1.00–1.48) and less likely among patients having advanced HIV disease at enrolment (RR: 0.65; 95% CI: 0.60–0.70).
Table 3. Multivariate analysis of comprehensive retention in care among 13 331 HIV-positive patients enrolled in care at 63 facilities in the Eastern and Nyanza regions of Kenya, January 2014 to March 2016
In our analysis of 13 331 HIV-infected patients enrolled in HIV care in Kenya, we found that the majority of clinical services were provided by nurses and clinical officers. Nurse-led ART services were associated with significantly higher comprehensive retention in HIV care and treatment and this was the only site-level characteristic significantly associated with retention in the multivariate analysis. In addition, when adjusting for both facility- and patient-level characteristics, nurse-led ART services remained significantly associated with higher rates of comprehensive retention of patients in HIV care.
Previously published studies have shown that nurse-managed ART does not compromise, and may improve, the quality of care for people living with HIV. In a systematic review of task-shifting, eight studies showed that nurse-managed HIV services in low-resource settings had outcomes similar to physician-led teams.13 Two randomized studies from South Africa also support the effectiveness of nurse-managed ART. A study at two health facilities near Cape Town and Johannesburg demonstrated that patients randomized to ART initiated by a physician and then monitored by a primary-care nurse had outcomes that were not inferior to patients randomized to physician-managed treatment.14 In the other study, a cluster-randomized trial showed equivalence of nurse-initiated versus physician-initiated ART at 31 health facilities in the Free State province of South Africa.15 In comparison to the previously published literature, our study is distinguished by its use of data from a larger number of health facilities, inclusion of both patient- and facility-level characteristics, the use of a novel outcome measure of comprehensive retention and the use of routine programmatic data.
Our findings also highlight the scarcity of physicians at HIV care settings in Kenya, even in urban and peri-urban areas. Only 8% of facilities had physician-led care, and only 11% of patients were being managed by a medical doctor. This is consistent with the situation in most low-resource settings where nurses, clinical officers and other non-physician clinicians provide the majority of health-care services.16–18 In sub-Saharan Africa, where the burden of HIV is the highest, nurses are the backbone of the health system.19,20
The strengths of this study include its novel measurement of quality of care, which combines a measure of retention in care with indicators of appropriate patient monitoring and initiation of treatment. Other strengths include the large number of patients and health facilities, and the inclusion of both patient- and facility-level parameters. The limitations include the non-random sample of health facilities, which were also limited to one country. While we adjusted for multiple patient and facility-level characteristics, the findings could have been affected by other parameters that we did not measure in this non-randomized study. The study focused on retention of patients and provision of key services; other important quality parameters that were not routinely collected at the time, such as achievement of viral suppression, patient satisfaction and quality of life, were not assessed and require further research.
In conclusion, using a comprehensive multi-component measure of quality of care, we demonstrated that patients at facilities offering nurse-led ART services were more likely to be retained in effective HIV care and treatment at 12 months after adjusting for facility- and patient-level characteristics. These findings confirm the central role of nurses in the achievement of global targets, including the 90–90–90 goals, and the need for further investment in nursing education, training and mentoring.
- Global AIDS update 2016. Geneva: Joint United Nations Programme on HIV/AIDS; 2016. Available from: http://www.unaids.org/sites/default/files/media_asset/global-AIDS-update-2016_en.pdf [cited 2016 Jun 13].
- How AIDS changed everything. MDG 6, 15 years, 15 lessons of hope from the AIDS response. Geneva: Joint United Nations Programme on HIV/AIDS; 2016. Available from: http://www.unaids.org/sites/default/files/media_asset/MDG6Report_en.pdf [cited 2016 Jun 13].
- AIDS by the numbers: 2015. Geneva: Joint United Nations Programme on HIV/AIDS; 2015. Available from: http://www.unaids.org/sites/default/files/media_asset/AIDS_by_the_numbers_2015_en.pdf [cited 2016 Jun 13].
- El-Sadr WM, Barker P, Rabkin M, Pillay Y, Birx D. Putting quality at the heart of HIV programs. AIDS. 2015 Jul;29 Suppl 2:S119–20. http://dx.doi.org/10.1097/QAD.0000000000000732 pmid: 26102621
- 90-90-90. An ambitious treatment target to help end the AIDS epidemic. Geneva: Joint United Nations Programme on HIV/AIDS; 2014. Available from: http://www.unaids.org/sites/default/files/media_asset/90-90-90_en_0.pdf [cited 2016 Jun 13].
- McNairy ML, El-Sadr WM. The HIV care continuum: no partial credit given. AIDS. 2012 Sep 10;26(14):1735–8. http://dx.doi.org/10.1097/QAD.0b013e328355d67b pmid: 22614888
- Roy M, Czaicki N, Holmes C, Chavan S, Tsitsi A, Odeny T, et al. Understanding sustained retention in HIV/AIDS care and treatment: a synthetic review. Curr HIV/AIDS Rep. 2016 Jun;13(3):177–85. http://dx.doi.org/10.1007/s11904-016-0317-9 pmid: 27188300
- Saito S, Howard AA, Chege D, Ellman TM, Ahoua L, Elul B, et al. Monitoring quality at scale: implementing quality assurance in a diverse, multicountry HIV program. AIDS. 2015 Jul;29 Suppl 2:S129–36. http://dx.doi.org/10.1097/QAD.0000000000000713 pmid: 26102623
- McNairy ML, Lamb MR, Abrams EJ, Elul B, Sahabo R, Hawken MP, et al.; Identifying Optimal Models of HIV Care and Treatment in Sub-Saharan Africa Study. Use of a comprehensive HIV care cascade for evaluating HIV program performance: findings from 4 sub-Saharan African countries. J Acquir Immune Defic Syndr. 2015 Oct 1;70(2):e44–51. http://dx.doi.org/10.1097/QAI.0000000000000745 pmid: 26375466
- National AIDS and STI Control Program. Guidelines on use of antiretroviral drugs for treating and preventing HIV infection: a rapid advice. Nairobi: Ministry of Health; 2014.
- Lahuerta M, Lima J, Elul B, Okamura M, Alvim MF, Nuwagaba-Biribonwoha H, et al. Patients enrolled in HIV care in Mozambique: baseline characteristics and follow-up outcomes. J Acquir Immune Defic Syndr. 2011 Nov 1;58(3):e75–86. http://dx.doi.org/10.1097/QAI.0b013e31822ac0a9 pmid: 21725246
- Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection: recommendations for a public health approach. 2nd ed. Annex 10. Geneva: World Health Organization; 2016.
- Callaghan M, Ford N, Schneider H. A systematic review of task- shifting for HIV treatment and care in Africa. Hum Resour Health. 2010 03 31;8:8. http://dx.doi.org/10.1186/1478-4491-8-8 pmid: 20356363
- Sanne I, Orrell C, Fox MP, Conradie F, Ive P, Zeinecker J, et al.; CIPRA-SA Study Team. Nurse versus doctor management of HIV-infected patients receiving antiretroviral therapy (CIPRA-SA): a randomised non-inferiority trial. Lancet. 2010 Jul 3;376(9734):33–40. http://dx.doi.org/10.1016/S0140-6736(10)60894-X pmid: 20557927
- Fairall L, Bachmann MO, Lombard C, Timmerman V, Uebel K, Zwarenstein M, et al. Task shifting of antiretroviral treatment from doctors to primary-care nurses in South Africa (STRETCH): a pragmatic, parallel, cluster-randomised trial. Lancet. 2012 Sep 8;380(9845):889–98. http://dx.doi.org/10.1016/S0140-6736(12)60730-2 pmid: 22901955
- Now more than ever: the contribution of nurses and midwives to primary health care. A compendium of primary care case studies: 38 case studies submitted by 29 countries across the 6 WHO regions. Geneva: World Health Organization; 2009. Available from: http://www.who.int/hrh/nursing_midwifery/compendium_hrh_studies.pdf [cited 2016 Jun 13].
- Treat train retain. Task shifting: global recommendations and guidelines. Geneva: World Health Organization; 2008. Available from: http://www.who.int/healthsystems/TTR-TaskShifting.pdf [cited 2016 Jun 13].
- Munjanja OK, Kibuka S, Dovlo D. The nursing workforce in sub-Saharan Africa. The Global Nursing Review Initiative, Issue 7. Geneva: International Council of Nurses; 2005. Available from: https://www.ghdonline.org/uploads/The_nursing_workforce_in_sub-Saharan_Africa.pdf [cited 2016 Jun 13].
- McCarthy CF, Voss J, Verani AR, Vidot P, Salmon ME, Riley PL. Nursing and midwifery regulation and HIV scale-up: establishing a baseline in East, Central and Southern Africa. J Int AIDS Soc. 2013 03 25;16(1):18051. http://dx.doi.org/10.7448/IAS.16.1.18051 pmid: 23531276
- Dovlo D. Migration of nurses from sub-Saharan Africa: a review of issues and challenges. Health Serv Res. 2007 Jun;42(3 Pt 2):1373–88. http://dx.doi.org/10.1111/j.1475-6773.2007.00712.x pmid: 17489920