Nurse-led HIV services and quality of care at health facilities in Kenya, 2014-2016.

Introduction 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 400000 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 Presidents 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. Methods 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. Data sources Patient-level data 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. …