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ABSTRACT
This retrospective cohort analysis was conducted to describe the association between adherence to clinic appointments and mortality, one year after enrollment into HIV care. We examined appointment-adherence for newly enrolled patients between January 2011 and December 2012 at a regional referral hospital in western Kenya. The outcomes of interest were patient default, risk factors for repeat default, and year-one risk of death. Of 582 enrolled patients, 258 (44%) were defaulters. GEE revealed that once having been defaulters, patients were significantly more likely to repeatedly default (OR 1.4; 95% CI 1.12-1.77), especially the unemployed (OR 1.43; 95% CI 1.07-1.91), smokers (OR 2.22; 95% CI 1.31-3.76), and those with no known disclosure (OR 2.17; 95% CI 1.42-3.3). Nineteen patients (3%) died during the follow-up period. Cox proportional hazards revealed that the risk of death was significantly higher among defaulters (HR 3.12; 95% CI 1.2-8.0) and increased proportionally to the rate of patient default; HR was 4.05 (95% CI1.38-11.81) and 4.98 (95% CI 1.45-17.09) for a cumulative of 4-60 and ≥60 days elapsed between all scheduled and actual clinic appointment dates, respectively. Risk factors for repeat default suggest a need to deliver targeted adherence programs.
Acknowledgements
We wish to acknowledge the contribution of the health-care workers and people living with HIV at the JOOTRH HIV clinic. We also thank the Kenya Ministry of Health, including the National AIDS and STI Control Program, the JOOTRH administration and the KEMRI Director for their collaboration in this evaluation. The findings and conclusions in this paper are those of the authors and do not necessarily represent the official position of the US Centers for Disease Control and Prevention/Government of Kenya. Authors contributions: Muthusi Kimeu took part in concept development, data management, and statistical analysis. Barbara Burmen took part in concept development, statistical analysis, and manuscript preparation and review. Beryl Audi, Anne Adega, Karen Owuor, Susan Arodi, and Dennis Bii took part in data collection and manuscript review. Emily Zielinski-Gutierrez provided technical oversight over manuscript writing, data analysis, and manuscript review.
Disclosure statement
No potential conflict of interest was reported by the authors.
Notes on contributers
Kimeu Muthusi currently serves as the Statistical consultant at the Food and Agriculture Organization of the United Nations (FAO), Somalia Office providing technical support in validating survey tools, developing statistical analysis plans, performing quantitative analyses and statistical abstracts on household resilience surveys conducted in Somalia. Previously, he worked as a Senior Statistician at the University of California in San-Francisco, Nairobi Office providing technical support to research officers in regard to the statistical aspects of research and program evaluation such as study design, sample size determination, power analysis, data management, analysis of data, and presentation of statistical information. Previously he was also attached to the HIV and TB Implementation Science and Services, HISS, Branch of KEMRI/CGHR as the Lead Statistician. He holds a Master of Science in Statistics, Universiteit Hasselt, Belgium, and Bachelor of Science in Mathematics and Statistics, Jomo Kenyatta University of Agriculture and Technology, Nairobi, Kenya. He also holds Professional – Graduate Statistician (GradStat) status at the Royal Statistical Society, United Kingdom.
Dr. Barbara Burmen currently serves as the HIV Implementation Science Coordinator at the HIV Implementation Science and Services Branch of the Kenya Medical Research Institute Center for Global Health Research. Her current duties include the use of routinely collected program data to generate scientific dissemination products with a view to ultimately improve program performance. Previously she has served as a Medical Officer in both the private and public health sector, where she was involved in the provision of HIV health services amongst others. She holds a Masters’ Degree in Public Health from the University of Liverpool Laureate Online Education and a Bachelors’ Degree in Medicine and Surgery from Moi University Eldoret, Kenya.
Berly Audi currently serves as the Community Activities Coordinator for the HIV Clinical Services HIV Implementation Science and Services Branch of the Kenya Medical Research Institute Center for Global Health Research. She previously worked as a Community Extension Officer at Care International. She holds a High Diploma in Community Health and Development, Great Lakes University, Kisumu, Kenya.
Anne Adega is currently a Research Officer with KEMRI /CDC HIV Implementation Science and Services program. She is involved in coordinating research studies within Operations Research section and supporting implementation science. She has previously coordinated studies in HIV Research branch of KEMRI/CDC. She holds a Master’s Degree Project Planning and Management and a Bachelor’s degree in Sociology both from University of Nairobi, Kenya.
Karen Owuor is currently a Research Officer with KEMRI/CDC HIV/AIDS Implementation Science and Services Program, Kisumu. She oversees the development, implementation, and evaluation of multiple research projects within HIV/AIDS and maternal, neonatal, and child health (MNCH) programs. Previously she served as senior nursing officer and coordinator of the nurse’s workforce project, Ministry of Health- Nyanza Province, Kenya. She holds a Master’s degree in Community Health and Development from Great Lakes University, Kenya and Bachelor’s Degree in Health Systems Development from the Catholic University of Eastern Africa.
Dr. Susan Arodi currently serves as the Medical Officer in Charge of the HIV Comprehensive Care Center at the Jaramogi Oginga Odinga Teaching and Referral Hospital. She has previously served as a Medical Officer in the Ministry of Health in various capacities. She holds a Bachelor’s Degree in Medicine and Surgery, University of Nairobi.
Dr. Dennis Bii served as the Program Head of the Clinical Services Section of the HIV Implementation Science and Services Branch of KEMRI CGHR at the time of submission. The clinical services section provided HIV Care and Treatment Services at the Jaramogi Oginga Oding Teaching and Referral Hospital HIV Comprehensive Care Clinic. He previously was the Lead Clinician for the HIV PreP study at the Kenya Medical Research Institute-University of San Francisco collaboration, Kisumu Kenya. He holds a Masters’ Degree in Public Health from the University of Umea International School of Public Health, Sweden and a Bachelors’ Degree in Medicine and Surgery from Moi University Eldoret, Kenya.
Dr. Emily Zielinski-Gutiérrez is the current Branch Chief, Surveillance and Epidemiology Branch of CDC Division of Global HIV AIDS, Kenya. Previously she served a Behavioral Scientist at CDC Division of Vector-Borne Diseases. She holds a Doctorate in Public Health, Tulane School of Public Health and Tropical Medicine, New Orleans Louisiana; a Master’s in Public Health Tulane School of Public Health and Tropical Medicine, New Orleans LA; and Bachelor of Arts, DePaul University.