Evolution of HIV Training for Enhanced Care Provision in Kenya: Challenges and Opportunities

Background: Healthcare worker capacity building efforts over the past decade have resulted in decentralisation of HIV prevention, care and treatment servicesObjective: To provide an overview of the evolution of HIV training in Kenya, from 2003 to dateData sources: Various Government of Kenya publications, policy documents and websites on training for HIV service delivery. Publications and websites of stakeholders, donors and partners as well. Journal articles, published peer reviewed literature, abstracts, websites and programme reports related to training for HIV treatment in Kenya and the region. Personal experiences of the authors who are trainers by mandate.Data selection: Data related to training for HIV treatment in Kenya and the region on websites and publications were scrutinised.Data extraction: All selected articles were read.Data synthesis: All the collected data together with the authors’  experiences were used for this publication.Conclusion: Accelerated in-service capacity building efforts have contributed to the success of decentralisation of HIV services. Pre-service HIV training provides an opportunity for sustaining the gains made so far, in the face of declining donor funds. Implementation of the proposed harmonized HIV curriculum in the setting of devolved healthcare provides an opportunity for partnerships between stakeholders involved in pre-service and in-service HIV training to ensure sustainability

Mortality from gastrointestinal congenital anomalies at 264 hospitals in 74 low-income, middle-income, and high-income countries: a multicentre, international, prospective cohort study

Background: Congenital anomalies are the fifth leading cause of mortality in children younger than 5 years globally. Many gastrointestinal congenital anomalies are fatal without timely access to neonatal surgical care, but few studies have been done on these conditions in low-income and middle-income countries (LMICs). We compared outcomes of the seven most common gastrointestinal congenital anomalies in low-income, middle-income, and high-income countries globally, and identified factors associated with mortality. // Methods: We did a multicentre, international prospective cohort study of patients younger than 16 years, presenting to hospital for the first time with oesophageal atresia, congenital diaphragmatic hernia, intestinal atresia, gastroschisis, exomphalos, anorectal malformation, and Hirschsprung's disease. Recruitment was of consecutive patients for a minimum of 1 month between October, 2018, and April, 2019. We collected data on patient demographics, clinical status, interventions, and outcomes using the REDCap platform. Patients were followed up for 30 days after primary intervention, or 30 days after admission if they did not receive an intervention. The primary outcome was all-cause, in-hospital mortality for all conditions combined and each condition individually, stratified by country income status. We did a complete case analysis. // Findings: We included 3849 patients with 3975 study conditions (560 with oesophageal atresia, 448 with congenital diaphragmatic hernia, 681 with intestinal atresia, 453 with gastroschisis, 325 with exomphalos, 991 with anorectal malformation, and 517 with Hirschsprung's disease) from 264 hospitals (89 in high-income countries, 166 in middle-income countries, and nine in low-income countries) in 74 countries. Of the 3849 patients, 2231 (58·0%) were male. Median gestational age at birth was 38 weeks (IQR 36–39) and median bodyweight at presentation was 2·8 kg (2·3–3·3). Mortality among all patients was 37 (39·8%) of 93 in low-income countries, 583 (20·4%) of 2860 in middle-income countries, and 50 (5·6%) of 896 in high-income countries (p<0·0001 between all country income groups). Gastroschisis had the greatest difference in mortality between country income strata (nine [90·0%] of ten in low-income countries, 97 [31·9%] of 304 in middle-income countries, and two [1·4%] of 139 in high-income countries; p≤0·0001 between all country income groups). Factors significantly associated with higher mortality for all patients combined included country income status (low-income vs high-income countries, risk ratio 2·78 [95% CI 1·88–4·11], p<0·0001; middle-income vs high-income countries, 2·11 [1·59–2·79], p<0·0001), sepsis at presentation (1·20 [1·04–1·40], p=0·016), higher American Society of Anesthesiologists (ASA) score at primary intervention (ASA 4–5 vs ASA 1–2, 1·82 [1·40–2·35], p<0·0001; ASA 3 vs ASA 1–2, 1·58, [1·30–1·92], p<0·0001]), surgical safety checklist not used (1·39 [1·02–1·90], p=0·035), and ventilation or parenteral nutrition unavailable when needed (ventilation 1·96, [1·41–2·71], p=0·0001; parenteral nutrition 1·35, [1·05–1·74], p=0·018). Administration of parenteral nutrition (0·61, [0·47–0·79], p=0·0002) and use of a peripherally inserted central catheter (0·65 [0·50–0·86], p=0·0024) or percutaneous central line (0·69 [0·48–1·00], p=0·049) were associated with lower mortality. // Interpretation: Unacceptable differences in mortality exist for gastrointestinal congenital anomalies between low-income, middle-income, and high-income countries. Improving access to quality neonatal surgical care in LMICs will be vital to achieve Sustainable Development Goal 3.2 of ending preventable deaths in neonates and children younger than 5 years by 2030

Editorial: Spontaneous bacterial peritonitis

No Abstract Availabl

Editorial Helicobacter pylori eradication in peptic dyspepsia

No Abstract. East African Medical Journal Vol 82(12) 2005: 601-60

Correlation of who clinical staging with CD4 counts in adult HIV/AIDS patients at Kenyatta National Hospital, Nairobi

Objective: To determine the degree of correlation between the WHO clinical staging and CD4 T-cell counts in HIV/AIDS adults at Kenyatta National Hospital, Nairobi.Design: Cross-sectional study.Setting: Kenyatta National Hospital, Nairobi.Subjects: One hundread and fifty two newly diagnosed HIV patients were recruited prospectively. Patients were first staged using the 2005 WHO clinical staging and then blood drawn for CD4 cell count.Results: The mean age in the study was 35 years, with females comprising 52.6% of the study group. The mean CD4 counts were 455, 420, 203 and 92 for WHO Stage 1, 2, 3 and 4 respectively. The sensitivity of the WHO clinical staging to predict CD4 counts of &gt;350cells/&#236;l was 63% with a specificity of 82%. The most common HIV clinical events were bacterial infections (33%), severe weight loss(28%) and tuberculosis(27%).Conclusions: There was correlation between the WHO clinical staging and expected CD4 T-cell count. However, the sensitivity was low and missed over a third of the patients in need of HAART. Majority of the patients presented in severe disease in need of HAART at the onset of their HIV diagnosis with 107 (70.3%) of the patients with Stage 3 or 4 disease and 114 (75%) of patients with CD4 counts of &lt;350 cells/&#236;l

Chronic kidney disease in rheumatoid arthritis at Kenyatta National Hospital

Objective: To determine the prevalence of chronic kidney disease among patients with rheumatoid arthritis on follow up at the rheumatology outpatient clinic at Kenyatta National Hospital.Design: Descriptive, cross-sectional study.Setting: Rheumatology outpatient clinic at the Kenyatta National Hospital, a public national and referral hospital.Subjects: Patients diagnosed to have rheumatoid arthritis who met the 2010 ACR-EULAR criteria.Results: Out of 104 patients recruited, 93 (89.4%) were female with a female to male ratio of 8.5:1. Mean age of patients was 48.7(±15.6) years. Majority of the patients (90%) were on at least one Disease Modifying Anti-Rheumatic Drug (DMARD) with methotrexate being the commonest used. Other DMARDs were leflunomide, sulfasalazine and hydroxychloroquine. None of our patients was on a biologic agent. Use of NSAIDs and/or prednisone was very frequent (88.5%). Median duration of disease since time of diagnosis was 4 years. Majority of patients (60%) had active disease. We found the prevalence of chronic kidney disease to be 28.7% (95% CI 19.1- 37.2%) based on estimated glomerular filtration rate using the Cockroft-Gault formula. Majority (50%) of which was stage 3a disease and none with end stage renal disease. We found no patients with proteinuria using urinary dipstick.Conclusion: Although we did not find any proteinuria in our study population, prevalence of chronic kidney disease based on estimated glomerular filtration rate was high with the majority having early stages of kidney disease. Use of urine strips alone is not an adequate screening tool

Prevalence of HCV and HCV/HIV co-infection among in-patients at the Kenyatta National Hospital

Objective: To determine the prevalence of HCV and HCV/HIV co-infection among medical in-patients at the Kenyatta National Hospital. Design: Prospective cross-sectional descriptive study. Setting: Kenyatta National Hospital, a tertiary referral and teaching hospital, in-patient department. Subjects: HIV/AIDS and HIV negative in-patients at KNH medical wards. Results: Among 458 HIV/AIDS medical in-patients, the prevalence of HCV was 3.7% while in the 518 HIV negative patients, it was 4.4%. The prevalence of co-infection with HCV and HIV was 3.7%. The incidence of risk factors in persons with HCV and/ or HIV infection(s) was low. Conclusion: This study found the prevalence of HCV infection among medical in-patients to be similar in HIV positive and HIV negative group of patients. The co-infection rates were low, as were the risk factors for transmission of these infections. East African Medical Journal Vol.82(4) 2005: 170-17

Prevalence of HCV and HIV/HCV co-infection among volunteer blood donors and VCT clients

Objective: To determine the prevalence of HCV infection and HCV/HIV co-infection among voluntary blood donors at the National Blood Transfusion Centre and clients at the Kenyatta National Hospital HIV-Voluntary Counselling and Testing (VCT) Centre. Design: A prospective cross-sectional descriptive study. Setting: Kenyatta National Hospital, a tertiary referral and teaching hospital and the National Blood Transfusion Services Centre, Nairobi. Subjects: Volunteer blood donors and VCT attendants. Results: The prevalence of HCV/HIV co-infection among 6154 blood donors in the NBTSC was very low, at 0.02. The HIV prevalence among the 353 KNH HIV-VCT clients was 9.3%, none of the clients tested positive for HCV. The incidence of risk factors in the persons with HCV and/or HIV infection(s) was low. Conclusion: The prevalence of HCV infection among pre-screened volunteer blood donors was low. However the current practice of screening all donated blood for HCV remains indispensable to prevent its transmission to blood recipients. East African Medical Journal Vol.82(4) 2005: 166-16

Prevalence of dyslipidemia and dysglycaemia in HIV infected patients

No Abstract. East African Medical Journal Vol. 85 (1) 2008 pp. 10-1

The Presentation and Outcome of Hiv-Related Disease in Nairobi

The range of clinical presentations of HIV-related disease in Africa has not been adequately described, despite the fact that many hospitals have to rely heavily on clinical diagnosis. Six hundred adult medical patients seen in the Casualty Department of the main Government hospital in Nairobi were enrolled in a study of the presentation and outcome of HIV-related disease: 506 of these patients were admitted, of whom 19 per cent (95) were HIV seropositive. The remaining 94 were dealt with as outpatients: 11 percent (10) of these were seropositive. A history of prior treatment for sexually transmitted disease and, if male, being uncircumcised, were associated with being seropositive. Three presentations were strongly associated with HIV infection: acute fever with no focus except the gastrointestinal tract (enteric fever-like illness), acute cough with fever (community-acquired pneumonia) and chronic diarrhoea with wasting. The WHO clinical case definition (CCD) for AIDS missed a substantial amount of HIV-related morbidity (sensitivity 39 per cent) and misidentified many seronegative patients (positive predictive value 59 per cent). In comparison with the Centers for Disease Control surveillance definition for AIDS, the CCD was specific (91 per cent) and sensitive (79 per cent) but only had a positive predictive values of 30 per cent: the CCD may therefore be a poor surveillance tool for AIDS. Seropositive patients were much more likely to die than were seronegative patients (39 per cent vs. 15 per cent mortality). Enteric fever-like illness was the presentation which most commonly proved fatal. A wider spectrum of disease is associated with underlying HIV immunosuppression than has previously been described in Africa