Estimation of the Population Size of Street- and Venue-Based Female Sex Workers and Sexually Exploited Minors in Rwanda in 2022: 3-Source Capture-Recapture.

BACKGROUND: HIV surveillance among key populations is a priority in all epidemic settings. Female sex workers (FSWs) globally as well as in Rwanda are disproportionately affected by the HIV epidemic; hence, the Rwanda HIV and AIDS National Strategic Plan (2018-2024) has adopted regular surveillance of population size estimation (PSE) of FSWs every 2-3 years. OBJECTIVE: We aimed at estimating, for the fourth time, the population size of street- and venue-based FSWs and sexually exploited minors aged ≥15 years in Rwanda. METHODS: In August 2022, the 3-source capture-recapture method was used to estimate the population size of FSWs and sexually exploited minors in Rwanda. The field work took 3 weeks to complete, with each capture occasion lasting for a week. The sample size for each capture was calculated using shinyrecap with inputs drawn from previously conducted estimation exercises. In each capture round, a stratified multistage sampling process was used, with administrative provinces as strata and FSW hotspots as the primary sampling unit. Different unique objects were distributed to FSWs in each capture round; acceptance of the unique object was marked as successful capture. Sampled FSWs for the subsequent capture occasions were asked if they had received the previously distributed unique object in order to determine recaptures. Statistical analysis was performed in R (version 4.0.5), and Bayesian Model Averaging was performed to produce the final PSE with a 95% credibility set (CS). RESULTS: We sampled 1766, 1848, and 1865 FSWs and sexually exploited minors in each capture round. There were 169 recaptures strictly between captures 1 and 2, 210 recaptures exclusively between captures 2 and 3, and 65 recaptures between captures 1 and 3 only. In all 3 captures, 61 FSWs were captured. The median PSE of street- and venue-based FSWs and sexually exploited minors in Rwanda was 37,647 (95% CS 31,873-43,354), corresponding to 1.1% (95% CI 0.9%-1.3%) of the total adult females in the general population. Relative to the adult females in the general population, the western and northern provinces ranked first and second with a higher concentration of FSWs, respectively. The cities of Kigali and eastern province ranked third and fourth, respectively. The southern province was identified as having a low concentration of FSWs. CONCLUSIONS: We provide, for the first time, both the national and provincial level population size estimate of street- and venue-based FSWs in Rwanda. Compared with the previous 2 rounds of FSW PSEs at the national level, we observed differences in the street- and venue-based FSW population size in Rwanda. Our study might not have considered FSWs who do not want anyone to know they are FSWs due to several reasons, leading to a possible underestimation of the true PSE.

HIV and hepatitis B, C co-infection and correlates of HIV infection among men who have sex with men in Rwanda, 2021: a respondent-driven sampling, cross-sectional study.

BACKGROUND: Men who have sex with men (MSM) are a key population group disproportionately affected by HIV and other sexually transmitted infections (STIs) worldwide. In Rwanda, the HIV epidemic remains a significant public health concern, and understanding the burden of HIV and hepatitis B and C coinfections among MSM is crucial for designing effective prevention and control strategies. This study aims to determine the prevalence of HIV, hepatitis B, and hepatitis C infections among MSM in Rwanda and identify correlates associated with HIV infection within this population. METHODS: We used respondent-driven sampling (RDS) to recruit participants between November and December 2021. A face-to-face, structured questionnaire was administered. Testing for HIV infection followed the national algorithm using two rapid tests: Alere Combo and STAT PAK as the first and second screening tests, respectively. Hepatitis B surface antigen (HBsAg) and anti-HCV tests were performed. All statistics were adjusted for RDS design, and a multivariable logistic regression model was constructed to identify factors associated with HIV infection. RESULTS: The prevalence of HIV among MSM was 6·9% (95% CI: 5·5-8·6), and among HIV-positive MSM, 12·9% (95% CI: 5·5-27·3) were recently infected. The prevalence of hepatitis B and C was 4·2% (95% CI: 3·0-5·7) and 0·7% (95% CI: 0·4-1·2), respectively. HIV and hepatitis B virus coinfection was 0·5% (95% CI: 0·2-1·1), whereas HIV and hepatitis C coinfection was 0·1% (95% CI: 0·0-0·5), and no coinfection for all three viruses was observed. MSM groups with an increased risk of HIV infection included those who ever suffered violence or abuse because of having sex with other men (AOR: 3·42; 95% CI: 1·87-6·25), those who refused to answer the question asking about 'ever been paid money, goods, or services for sex' (AOR: 10·4; 95% CI: 3·30-32·84), and those not consistently using condoms (AOR: 3·15; 95% CI: 1·31-7·60). CONCLUSION: The findings suggest more targeted prevention and treatment approaches and underscore the importance of addressing structural and behavioral factors contributing to HIV vulnerability, setting interventions to reduce violence and abuse against MSM, promoting safe and consensual sexual practices, and expanding access to HIV prevention tools such as condoms and preexposure prophylaxis (PrEP).

Implementation of an HIV Case Based Surveillance Using Standards-Based Health Information Exchange in Rwanda.

As Rwanda approaches the UNAIDS Fast Track goals which recommend that 95% of HIV-infected individuals know their status, of whom 95% should receive treatment and 95% of those on treatment achieve viral suppression, the country currently relies on an inefficient paper, and disjointed electronic, systems for case-based surveillance (CBS). Rwanda has established an ecosystem of interoperable systems based on open standards to support HIV CBS. Data were successfully exchanged between an EMR, a client registry, laboratory information system and DHIS-2 Tracker, and subsequently, a complete analytic dataset was ingested into MS-Power Business Intelligence (MS-PowerBI) for analytics and visualization of the CBS data. Existing challenges included inadequate workforce capacity to support mapping of data elements to HL7 FHIR resources. Interoperability optimization to support CBS is work in progress and rigorous evaluations on the effect on health information exchange on monitoring patient outcomes are needed.

Population Size Estimation of Men Who Have Sex With Men in Rwanda: Three-Source Capture-Recapture Method.

BACKGROUND: Globally, men who have sex with men (MSM) continue to bear a disproportionately high burden of HIV infection. Rwanda experiences a mixed HIV epidemic, which is generalized in the adult population, with aspects of a concentrated epidemic among certain key populations at higher risk of HIV infection, including MSM. Limited data exist to estimate the population size of MSM at a national scale; hence, an important piece is missing in determining the denominators to use in estimates for policy makers, program managers, and planners to effectively monitor HIV epidemic control. OBJECTIVE: The aims of this study were to provide the first national population size estimate (PSE) and geographic distribution of MSM in Rwanda. METHODS: Between October and December 2021, a three-source capture-recapture method was used to estimate the MSM population size in Rwanda. Unique objects were distributed to MSM through their networks (first capture), who were then tagged according to MSM-friendly service provision (second capture), and a respondent-driven sampling survey was used as the third capture. Capture histories were aggregated in a 2k-1 contingency table, where k indicates the number of capture occasions and "1" and "0" indicate captured and not captured, respectively. Statistical analysis was performed in R (version 4.0.5) and the Bayesian nonparametric latent-class capture-recapture package was used to produce the final PSE with 95% credibility sets (CS). RESULTS: We sampled 2465, 1314, and 2211 MSM in capture one, two, and three, respectively. There were 721 recaptures between captures one and two, 415 recaptures between captures two and three, and 422 recaptures between captures one and three. There were 210 MSM captured in all three captures. The total estimated population size of MSM above 18 years old in Rwanda was 18,100 (95% CS 11,300-29,700), corresponding to 0.70% (95% CI 0.4%-1.1%) of total adult males. Most MSM reside in the city of Kigali (7842, 95% CS 4587-13,153), followed by the Western province (2469, 95% CS 1994-3518), Northern province (2375, 95% CS 842-4239), Eastern province (2287, 95% CS 1927-3014), and Southern province (2109, 95% CS 1681-3418). CONCLUSIONS: Our study provides, for the first time, a PSE of MSM aged 18 years or older in Rwanda. MSM are concentrated in the city of Kigali and are almost evenly distributed across the other 4 provinces. The national proportion estimate bounds of MSM out of the total adult males includes the World Health Organization's minimum recommended proportion (at least 1.0%) based on 2012 census population projections for 2021. These results will inform denominators to be used for estimating service coverage and fill existing information gaps to enable policy makers and planners to monitor the HIV epidemic among MSM nationally. There is an opportunity for conducting small-area MSM PSEs for subnational-level HIV treatment and prevention interventions.

Assessment of Stakeholder Perceptions and Attitudes Toward Health Data Governance Principles in Botswana: Web-Based Survey.

BACKGROUND: The use of information and communication technologies for health-eHealth-is described as having potential to improve the quality of health care service delivery. Consequently, there is an increased global trend toward adoption of eHealth interventions by health care systems worldwide. Despite the proliferation of eHealth solutions, many health care institutions especially in transitioning countries are struggling to attain effective data governance approaches. The Ministry of Health in Botswana is an exemplar institution continually seeking better approaches to strengthen health data governance (HDG) approaches following the adoption of eHealth solutions. Recognizing the need for a global HDG framework, the Transform Health coalition conceptualized HDG principles that are structured around 3 interconnected objectives: protecting people, promoting the value of health, and prioritizing equity. OBJECTIVE: The aim of the study is to solicit and evaluate perceptions and attitudes of health sector workers in Botswana toward the HDG principles by Transform Health and derive any future guidance. METHODS: Purposive sampling was used to select participants. A total of 23 participants from various health care organizations in Botswana completed a web-based survey and 10 participated in a follow-up remote round-table discussion. The aim of the round-table discussion was to gain further insight into participants' responses from the web-based survey. Participants were from the following health care cadres: nurses, doctors, information technology professionals, and health informaticians. Both validity and reliability testing were performed for the survey tool before sharing it with study participants. An analysis of participants' close-ended responses from the survey was performed using descriptive statistics. Thematic analysis of open-ended responses from the questionnaire and the round-table discussion was achieved using the Delve software and the widely accepted principles of thematic analysis. RESULTS: Although some participants highlighted having measures in place similar to the HDG principles, there were some who either did not know or disagreed that their organizations already had in place mechanisms similar to the proposed HDG principles. Participants further expressed relevance and importance of the HDG principles in the context of Botswana. However, some modifications to the principles were also suggested. CONCLUSIONS: This study highlights the necessity of data governance in health care particularly toward meeting the requirements for Universal Health Coverage. The existence of other health data governance frameworks calls for a critical analysis to assess the most appropriate and applicable framework in the context of Botswana and similar transitioning countries. An organization-centered approach may be most appropriate, as well as strengthening of existing organizations' HDG practices with the Transform Health principles.

A clinical decision support system is associated with reduced loss to follow-up among patients receiving HIV treatment in Kenya: a cluster randomized trial.

BACKGROUND: Loss to follow-up (LFTU) among HIV patients remains a major obstacle to achieving treatment goals with the risk of failure to achieve viral suppression and thereby increased HIV transmission. Although use of clinical decision support systems (CDSS) has been shown to improve adherence to HIV clinical guidance, to our knowledge, this is among the first studies conducted to show its effect on LTFU in low-resource settings. METHODS: We analyzed data from a cluster randomized controlled trial in adults and children (aged ≥ 18 months) who were receiving antiretroviral therapy at 20 HIV clinics in western Kenya between Sept 1, 2012 and Jan 31, 2014. Participating clinics were randomly assigned, via block randomization. Clinics in the control arm had electronic health records (EHR) only while the intervention arm had an EHR with CDSS. The study objectives were to assess the effects of a CDSS, implemented as alerts on an EHR system, on: (1) the proportion of patients that were LTFU, (2) LTFU patients traced and successfully linked back to treatment, and (3) time from enrollment on the study to documentation of LTFU. RESULTS: Among 5901 eligible patients receiving ART, 40.6% (n = 2396) were LTFU during the study period. CDSS was associated with lower LTFU among the patients (Adjusted Odds Ratio-aOR 0.70 (95% CI 0.65-0.77)). The proportions of patients linked back to treatment were 25.8% (95% CI 21.5-25.0) and 30.6% (95% CI 27.9-33.4)) in EHR only and EHR with CDSS sites respectively. CDSS was marginally associated with reduced time from enrollment on the study to first documentation of LTFU (adjusted Hazard Ratio-aHR 0.85 (95% CI 0.78-0.92)). CONCLUSION: A CDSS can potentially improve quality of care through reduction and early detection of defaulting and LTFU among HIV patients and their re-engagement in care in a resource-limited country. Future research is needed on how CDSS can best be combined with other interventions to reduce LTFU. Trial registration NCT01634802. Registered at www.clinicaltrials.gov on 12-Jul-2012. Registered prospectively.

Success of a South-South collaboration on Human Resources Information Systems (HRIS) in health: a case of Kenya and Zambia HRIS collaboration.

BACKGROUND: Shortage of health workforce in most African countries is a major impediment to achieving health and development goals. Countries are encouraged to develop evidence-based strategies to scale up their health workforce in order to bridge the gap. South-South collaborations have gained popularity due to similarities in the challenges faced in the region. This strategy has been used in trade, education, and health sector among others. This paper is a road map of using a South-South collaboration to develop a Human Resources Information System (HRIS) to inform scale-up of the health workforce. CASE PRESENTATION: In the last decade, Kenya implemented one of the most comprehensive HRIS in Africa. The HRIS was funded by the US President's Emergency Plan for AIDS Relief (PEPFAR) through the Centers for Disease Control and Prevention (CDC) and implemented by Emory University. The Kenyan team collaborated with the Zambian team to establish a similar HRIS in Zambia. This case study describes the collaboration activities between Zambia and Kenya which included needs assessment, establishment of project office, stakeholders' sensitization, technical assistance and knowledge transfer, software reuse, documents and guidelines reuse, project structure and management, and project formative evaluation. Furthermore, it highlights the need for adopting effective communication strategies, collaborative planning, teamwork, willingness to learn, and having minimum technical skills from the recipient country as lessons learned from the collaboration. As a result of the collaboration, while Kenya took 5 years, Zambia was able to implement the project within 2 years which is less than half the time it took Kenya. CONCLUSIONS: This case presents a unique experience in the use of South-South collaboration in establishing a HRIS. It illustrates the steps and resources needed while identifying the successes and challenges in undertaking such collaboration.

Finding Hidden HIV Clusters to Support Geographic-Oriented HIV Interventions in Kenya.

BACKGROUND: In a spatially well known and dispersed HIV epidemic, identifying geographic clusters with significantly higher HIV prevalence is important for focusing interventions for people living with HIV (PLHIV). METHODS: We used Kulldorff spatial-scan Poisson model to identify clusters with high numbers of HIV-infected persons 15-64 years old. We classified PLHIV as belonging to either higher prevalence or lower prevalence (HP/LP) clusters, then assessed distributions of sociodemographic and biobehavioral HIV risk factors and associations with clustering. RESULTS: About half of survey locations, 112/238 (47%) had high rates of HIV (HP clusters), with 1.1-4.6 times greater PLHIV adults observed than expected. Richer persons compared with respondents in lowest wealth index had higher odds of belonging to a HP cluster, adjusted odds ratio (aOR) 1.61 [95% confidence interval (CI): 1.13 to 2.3], aOR 1.66 (95% CI: 1.09 to 2.53), aOR 3.2 (95% CI: 1.82 to 5.65), and aOR 2.28 (95% CI: 1.09 to 4.78) in second, middle, fourth, and highest quintiles, respectively. Respondents who perceived themselves to have greater HIV risk or were already HIV-infected had higher odds of belonging to a HP cluster, aOR 1.96 (95% CI: 1.13 to 3.4) and aOR 5.51 (95% CI: 2.42 to 12.55), respectively; compared with perceived low risk. Men who had ever been clients of female sex worker had higher odds of belonging to a HP cluster than those who had never been, aOR 1.47 (95% CI: 1.04 to 2.08); and uncircumcised men vs circumcised, aOR 3.2 (95% CI: 1.74 to 5.8). CONCLUSIONS: HIV infection in Kenya exhibits localized geographic clustering associated with sociodemographic and behavioral factors, suggesting disproportionate exposure to higher HIV risk. Identification of these clusters reveals the right places for targeting priority-tailored HIV interventions.

A national standards-based assessment on functionality of electronic medical records systems used in Kenyan public-Sector health facilities.

BACKGROUND: Variations in the functionality, content and form of electronic medical record systems (EMRs) challenge national roll-out of these systems as part of a national strategy to monitor HIV response. To enforce the EMRs minimum requirements for delivery of quality HIV services, the Kenya Ministry of Health (MoH) developed EMRs standards and guidelines. The standards guided the recommendation of EMRs that met a preset threshold for national roll-out. METHODS: Using a standards-based checklist, six review teams formed by the MoH EMRs Technical Working Group rated a total of 17 unique EMRs in 28 heath facilities selected by individual owners for their optimal EMR implementation. EMRs with an aggregate score of ≥60% against checklist criteria were identified by the MoH as suitable for upgrading and rollout to Kenyan public health facilities. RESULTS: In Kenya, existing EMRs scored highly in health information and reporting (mean score=71.8%), followed by security, system features, core clinical information, and order entry criteria (mean score=58.1%-55.9%), and lowest against clinical decision support (mean score=17.6%) and interoperability criteria (mean score=14.3%). Four EMRs met the 60.0% threshold: OpenMRS, IQ-Care, C-PAD and Funsoft. On the basis of the review, the MoH provided EMRs upgrade plans to owners of all the 17 systems reviewed. CONCLUSION: The standards-based review in Kenya represents an effort to determine level of conformance to the EMRs standards and prioritize EMRs for enhancement and rollout. The results support concentrated use of resources towards development of the four recommended EMRs. Further review should be conducted to determine the effect of the EMR-specific upgrade plans on the other 13 EMRs that participated in the review exercise.

Evaluation of Health IT in Low-Income Countries.

Low and middle income countries (LMICs) bear a disproportionate burden of major global health challenges. Health IT could be a promising solution in these settings but LMICs have the weakest evidence of application of health IT to enhance quality of care. Various systematic reviews show significant challenges in the implementation and evaluation of health IT. Key barriers to implementation include lack of adequate infrastructure, inadequate and poorly trained health workers, lack of appropriate legislation and policies and inadequate financial 333indicating the early state of generation of evidence to demonstrate the effectiveness of health IT in improving health outcomes and processes. The implementation challenges need to be addressed. The introduction of new guidelines such as GEP-HI and STARE-HI, as well as models for evaluation such as SEIPS, and the prioritization of evaluations in eHealth strategies of LMICs provide an opportunity to focus on strategic concepts that transform the demands of a modern integrated health care system into solutions that are secure, efficient and sustainable.

Effect of a clinical decision support system on early action on immunological treatment failure in patients with HIV in Kenya: a cluster randomised controlled trial.

BACKGROUND: A clinical decision support system (CDSS) is a computer program that applies a set of rules to data stored in electronic health records to offer actionable recommendations. We aimed to establish whether a CDSS that supports detection of immunological treatment failure among patients with HIV taking antiretroviral therapy (ART) would improve appropriate and timely action. METHODS: We did this prospective, cluster randomised controlled trial in adults and children (aged ≥18 months) who were eligible for, and receiving, ART at HIV clinics in Siaya County, western Kenya. Health facilities were randomly assigned (1:1), via block randomisation (block size of two) with a computer-generated random number sequence, to use electronic health records either alone (control) or with CDSS (intervention). Facilities were matched by type and by number of patients enrolled in HIV care. The primary outcome measure was the difference between groups in the proportion of patients who experienced immunological treatment failure and had a documented clinical action. We used generalised linear mixed models with random effects to analyse clustered data. This trial is registered with ClinicalTrials.gov, number NCT01634802. FINDINGS: Between Sept 1, 2012, and Jan 31, 2014, 13 clinics, comprising 41,062 patients, were randomly assigned to the control group (n=6) or the intervention group (n=7). Data collection at each site took 12 months. Among patients eligible for ART, 10,358 (99%) of 10,478 patients were receiving ART at control sites and 10,991 (99%) of 11,028 patients were receiving ART at intervention sites. Of these patients, 1125 (11%) in the control group and 1342 (12%) in the intervention group had immunological treatment failure, of whom 332 (30%) and 727 (54%), respectively, received appropriate action. The likelihood of clinicians taking appropriate action on treatment failure was higher with CDSS alerts than with no decision support system (adjusted odds ratio 3·18, 95% CI 1·02-9·87). INTERPRETATION: CDSS significantly improved the likelihood of appropriate and timely action on immunological treatment failure. We expect our findings will be generalisable to virological monitoring of patients with HIV receiving ART once countries implement the 2015 WHO recommendation to scale up viral load monitoring. FUNDING: US President's Emergency Plan for AIDS Relief (PEPFAR), through the US Centers for Disease Control and Prevention.

Automating indicator data reporting from health facility EMR to a national aggregate data system in Kenya: An Interoperability field-test using OpenMRS and DHIS2.

Introduction: Developing countries are increasingly strengthening national health information systems (HIS) for evidence-based decision-making. However, the inability to report indicator data automatically from electronic medical record systems (EMR) hinders this process. Data are often printed and manually re-entered into aggregate reporting systems. This affects data completeness, accuracy, reporting timeliness, and burdens staff who support routine indicator reporting from patient-level data. Method: After conducting a feasibility test to exchange indicator data from Open Medical Records System (OpenMRS) to District Health Information System version 2 (DHIS2), we conducted a field test at a health facility in Kenya. We configured a field-test DHIS2 instance, similar to the Kenya Ministry of Health (MOH) DHIS2, to receive HIV care and treatment indicator data and the KenyaEMR, a customized version of OpenMRS, to generate and transmit the data from a health facility. After training facility staff how to send data using DHIS2 reporting module, we compared completeness, accuracy and timeliness of automated indicator reporting with facility monthly reports manually entered into MOH DHIS2. Results: All 45 data values in the automated reporting process were 100% complete and accurate while in manual entry process, data completeness ranged from 66.7% to 100% and accuracy ranged from 33.3% to 95.6% for seven months (July 2013-January 2014). Manual tally and entry process required at least one person to perform each of the five reporting activities, generating data from EMR and manual entry required at least one person to perform each of the three reporting activities, while automated reporting process had one activity performed by one person. Manual tally and entry observed in October 2013 took 375 minutes. Average time to generate data and manually enter into DHIS2 was over half an hour (M=32.35 mins, SD=0.29) compared to less than a minute for automated submission (M=0.19 mins, SD=0.15). Discussion and Conclusion: The results indicate that indicator data sent electronically from OpenMRS-based EMR at a health facility to DHIS2 improves data completeness, eliminates transcription errors and delays in reporting, and reduces the reporting burden on human resources. This increases availability of quality indicator data using available resources to facilitate monitoring service delivery and measuring progress towards set goals.

Do interoperable national information systems enhance availability of data to assess the effect of scale-up of HIV services on health workforce deployment in resource-limited countries?

Sub-Saharan Africa (SSA) bears the heaviest burden of the HIV epidemic. Health workers play a critical role in the scale-up of HIV programs. SSA also has the weakest information and communication technology (ICT) infrastructure globally. Implementing interoperable national health information systems (HIS) is a challenge, even in developed countries. Countries in resource-limited settings have yet to demonstrate that interoperable systems can be achieved, and can improve quality of healthcare through enhanced data availability and use in the deployment of the health workforce. We established interoperable HIS integrating a Master Facility List (MFL), District Health Information Software (DHIS2), and Human Resources Information Systems (HRIS) through application programmers interfaces (API). We abstracted data on HIV care, health workers deployment, and health facilities geo-coordinates. Over 95% of data elements were exchanged between the MFL-DHIS and HRIS-DHIS. The correlation between the number of HIV-positive clients and nurses and clinical officers in 2013 was R2=0.251 and R2=0.261 respectively. Wrong MFL codes, data type mis-match and hyphens in legacy data were key causes of data transmission errors. Lack of information exchange standards for aggregate data made programming time-consuming.

A structured approach to recording AIDS-defining illnesses in Kenya: A SNOMED CT based solution.

INTRODUCTION: Several studies conducted in sub-Saharan Africa (SSA) have shown that routine clinical data in HIV clinics often have errors. Lack of structured and coded documentation of diagnosis of AIDS defining illnesses (ADIs) can compromise data quality and decisions made on clinical care. METHODS: We used a structured framework to derive a reference set of concepts and terms used to describe ADIs. The four sources used were: (i) CDC/Accenture list of opportunistic infections, (ii) SNOMED Clinical Terms (SNOMED CT), (iii) Focus Group Discussion (FGD) among clinicians and nurses attending to patients at a referral provincial hospital in western Kenya, and (iv) chart abstraction from the Maternal Child Health (MCH) and HIV clinics at the same hospital. Using the January 2014 release of SNOMED CT, concepts were retrieved that matched terms abstracted from approach iii & iv, and the content coverage assessed. Post-coordination matching was applied when needed. RESULTS: The final reference set had 1054 unique ADI concepts which were described by 1860 unique terms. Content coverage of SNOMED CT was high (99.9% with pre-coordinated concepts; 100% with post-coordination). The resulting reference set for ADIs was implemented as the interface terminology on OpenMRS data entry forms. CONCLUSION: Different sources demonstrate complementarity in the collection of concepts and terms for an interface terminology. SNOMED CT provides a high coverage in the domain of ADIs. Further work is needed to evaluate the effect of the interface terminology on data quality and quality of care.

Association between HIV programs and quality of maternal health inputs and processes in Kenya.

We assessed whether quality of maternal and newborn health services is influenced by presence of HIV programs at Kenyan health facilities using data from a national facility survey. Facilities that provided services to prevent mother-to-child HIV transmission had better prenatal and postnatal care inputs, such as infrastructure and supplies, and those providing antiretroviral therapy had better quality of prenatal and postnatal care processes. HIV-related programs may have benefits for quality of care for related services in the health system.

Better adherence to pre-antiretroviral therapy guidelines after implementing an electronic medical record system in rural Kenyan HIV clinics: a multicenter pre-post study.

INTRODUCTION: The monitoring of pre-antiretroviral therapy (pre-ART) is a key indicator of HIV quality of care. This study investigated the association of an electronic medical record system (EMR) with adherence to pre-ART guidelines in rural HIV clinics in Kenya. METHODS: A retrospective study was carried out to assess the quality of pre-ART care using three indicators: (1) the performance of a baseline CD4 test, (2) time from enrollment in care to first CD4 test, and (3) time from baseline CD4 to second CD4 test. A comparison of these indicators was made pre and post the introduction of an EMR system in 17 rural HIV clinics. RESULTS: A total of 18523 patients were receiving pre-ART care, of whom 38.8% in the paper group had had at least one CD4 test compared to 53.4% in the EMR group (p<0.001). The adjusted odds of performing a CD4 test in clinics using an EMR was 1.59 (95% confidence interval 1.49-1.69). The median time from enrolment into HIV care to first CD4 test was 1.40 months (interquartile range (IQR) 0.47-4.87) for paper vs. 0.93 months (IQR 0.43-3.37) for EMR. The median time from baseline to first CD4 follow-up was 7.5 months (IQR 5.97-10.73) for paper and 6.53 months (IQR 5.57-7.87) for EMR. CONCLUSION: The use of the EMR system was associated with better compliance to HIV guidelines for pre-ART care. EMRs have a potential positive impact on quality of care for HIV patients in resource-constrained settings.

Electronic medical record systems are associated with appropriate placement of HIV patients on antiretroviral therapy in rural health facilities in Kenya: a retrospective pre-post study.

BACKGROUND AND OBJECTIVE: There is little evidence that electronic medical record (EMR) use is associated with better compliance with clinical guidelines on initiation of antiretroviral therapy (ART) among ART-eligible HIV patients. We assessed the effect of transitioning from paper-based to an EMR-based system on appropriate placement on ART among eligible patients. METHODS: We conducted a retrospective, pre-post EMR study among patients enrolled in HIV care and eligible for ART at 17 rural Kenyan clinics and compared the: (1) proportion of patients eligible for ART based on CD4 count or WHO staging who initiate therapy; (2) time from eligibility for ART to ART initiation; (3) time from ART initiation to first CD4 test. RESULTS: 7298 patients were eligible for ART; 54.8% (n=3998) were enrolled in HIV care using a paper-based system while 45.2% (n=3300) were enrolled after the implementation of the EMR. EMR was independently associated with a 22% increase in the odds of initiating ART among eligible patients (adjusted OR (aOR) 1.22, 95% CI 1.12 to 1.33). The proportion of ART-eligible patients not receiving ART was 20.3% and 15.1% for paper and EMR, respectively (χ(2)=33.5, p<0.01). Median time from ART eligibility to ART initiation was 29.1 days (IQR: 14.1-62.1) for paper compared to 27 days (IQR: 12.9-50.1) for EMR. CONCLUSIONS: EMRs can improve quality of HIV care through appropriate placement of ART-eligible patients on treatment in resource limited settings. However, other non-EMR factors influence timely initiation of ART.

Tuberculosis and HIV at the national level in Kenya: results from the Second Kenya AIDS Indicator Survey.

BACKGROUND: Co-morbidity with tuberculosis and HIV is a common cause of mortality in sub-Saharan Africa. In the second Kenya AIDS Indicator Survey, we collected data on knowledge and experience of HIV and tuberculosis, as well as on access to and coverage of relevant treatment services and antiretroviral therapy (ART) in Kenya. METHODS: A national, population-based household survey was conducted from October 2012 to February 2013. Information was collected through household questionnaires, and blood samples were taken for HIV, CD4 cell counts, and HIV viral load testing at a central laboratory. RESULTS: Overall, 13,720 persons aged 15-64 years participated; 96.7% [95% confidence interval (CI): 96.3 to 97.1] had heard of tuberculosis, of whom 2.0% (95% CI: 1.7 to 2.2) reported having prior tuberculosis. Among those with laboratory-confirmed HIV infection, 11.6% (95% CI: 8.9 to 14.3) reported prior tuberculosis. The prevalence of laboratory-confirmed HIV infection in persons reporting prior tuberculosis was 33.2% (95% CI: 26.2 to 40.2) compared to 5.1% (95% CI: 4.5 to 5.8) in persons without prior tuberculosis. Among those in care, coverage of ART for treatment-eligible persons was 100% for those with prior tuberculosis and 88.6% (95% CI: 81.6 to 95.7) for those without. Among all HIV-infected persons, ART coverage among treatment-eligible persons was 86.9% (95% CI: 74.2 to 99.5) for persons with prior tuberculosis and 58.3% (95% CI: 47.6 to 69.0) for those without. CONCLUSIONS: Morbidity from tuberculosis and HIV remain major health challenges in Kenya. Tuberculosis is an important entry point for HIV diagnosis and treatment. Lack of knowledge of HIV serostatus is an obstacle to access to HIV services and timely ART for prevention of HIV transmission and HIV-associated disease, including tuberculosis.

Using information and communications technology in a national population-based survey: the Kenya AIDS Indicator Survey 2012.

BACKGROUND: With improvements in technology, electronic data capture (EDC) for large surveys is feasible. EDC offers benefits over traditional paper-based data collection, including more accurate data, greater completeness of data, and decreased data cleaning burden. METHODS: The second Kenya AIDS Indicator Survey (KAIS 2012) was a population-based survey of persons aged 18 months to 64 years. A software application was designed to capture the interview, specimen collection, and home-based testing and counseling data. The application included: interview translations for local languages; options for single, multiple, and fill-in responses; and automated participant eligibility determination. Data quality checks were programmed to automate skip patterns and prohibit outlier responses. A data sharing architecture was developed to transmit the data in real-time from the field to a central server over a virtual private network. RESULTS: KAIS 2012 was conducted between October 2012 and February 2013. Overall, 68,202 records for the interviews, specimen collection, and home-based testing and counseling were entered into the application. Challenges arose during implementation, including poor connectivity and a systems malfunction that created duplicate records, which prevented timely data transmission to the central server. Data cleaning was minimal given the data quality control measures. CONCLUSIONS: KAIS 2012 demonstrated the feasibility of using EDC in a population-based survey. The benefits of EDC were apparent in data quality and minimal time needed for data cleaning. Several important lessons were learned, such as the time and monetary investment required before survey implementation, the importance of continuous application testing, and contingency plans for data transmission due to connectivity challenges.

Medical injection use among adults and adolescents aged 15 to 64 years in Kenya: results from a national survey.

BACKGROUND: Unsafe medical injections remain a potential route of HIV transmission in Kenya. We used data from a national survey in Kenya to study the magnitude of medical injection use, medication preference, and disposal of medical waste in the community. METHODS: The Kenya AIDS Indicator Survey 2012 was a nationally representative population-based survey. Among participants aged 15-64 years, data were collected regarding medical injections received in the year preceding the interview; blood samples were collected from participants for HIV testing. RESULTS: Of the 13,673 participants who answered questions on medical injections, 35.9% [95% confidence interval (CI): 34.5 to 37.3] reported receiving ≥1 injection in the past 12 months and 51.2% (95% CI: 49.7 to 52.8) preferred receiving an injection over a pill. Among those who received an injection from a health care provider, 95.9% (95% CI: 95.2 to 96.7) observed him/her open a new injection pack, and 7.4% (95% CI: 6.4 to 8.4) had seen a used syringe or needle near their home or community in the past 12 months. Men who had received ≥1 injection in the past 12 months (adjusted odds ratio, 3.2; 95% CI: 1.2 to 8.9) and women who had received an injection in the past 12 months, not for family planning purposes (adjusted odds ratio, 2.6; 95% CI: 1.2 to 5.5), were significantly more likely to be HIV infected compared with those who had not received medical injection in the past 12 months. CONCLUSIONS: Injection preference may contribute to high rates of injections in Kenya. Exposure to unsafe medical waste in the community poses risks for injury and infection. We recommend that community- and facility-based injection safety strategies be integrated in disease prevention programs.