Mobile telemedicine for Community Health Worker HIV Care: A pilot study in Nairobi, Kenya

1. Mobile telemedicine for Community Health Worker HIV Care: A pilot study in Nairobi, Kenya Jennifer Cohn, MD MPH University of Pennsylvania School of Medicine

2. Background • Scale up vs HCW shortage • Use of CHW for HIV care • WHO Task Shifting Report (2007) • Evidence of health systems benefit • Evidence of clinical benefit • Country guidelines • Challenges • Poor clinical support of CHWs in field • Poor linkage of CHIS to formal HIS WHO. Task shifting, 2007 Celletti et al., AIDS 2010 Decroo et al, JAIDS 2010 MSF Khayelitsha programme report, 2011

3. Background: Kenya • HIV • 1.6 million HIV • 540,000 on ART • Changing guidelines • Health workforce shortage • Nurses 1.18 per 1000 • Doctors 0.14 per 1000 • Kenya Community Health Strategy • Developed 2006, roll-out 2009 • Level 1 of the health system • Aid in delivery of Kenya EHP • Supports CHWs in a variety of tasks, links to an RN supervisor • Link CHIS to HIS • Interim reviews

4. The Pilot Study • Goals • Support CHW clinical-decision making • Link CHIS to HIS • Innovation • Branched logic surveys • Easy-to-use interface • Real-time upload to server • Aims • Assess ability of CHWs to learn and use mHealth application • Assess function and connectivity of server • Assess patient outcomes (earlier return to clinic, clinician action). • Setting • Nairobi, Kenya • Mbagathi District Hospital • Subjects • 17 CHWs • Convenience sampling

5. The Pilot Study: Methods • CHW activities • 1st line ART initiation • 2nd line ART initiation • Defaulters • Post-hospitalization • Clinician request • Training • Standard 4 hour, didactic and role play • 2 Facilitators • Use for 6 weeks

6. The Pilot Study: Methods • CHW activities • 1st line ART initiation • 2nd line ART initiation • Defaulters • Post-hospitalization • Clinician request • Training • Standard 4 hour, didactic and role play • 2 Facilitators • Use for 6 weeks

7. Evaluation Tools • Ability to learn and use technology • Role play • Time 0, 3 and 6 weeks • Satisfaction • Survey (Likert scale) • Time 0 and 6 weeks • Server function • Server downtimes • Failed uploads • Patient outcomes • Red flags • Chart review

8. Results: CHW Demographics and Server Function • Server Functioning • Downtime: 1 episode lasting 33 hours • Survey transmission • 78 total • 16 (20.5%) uploaded >24 hours • 6 (7.7%) uploaded greater than 48 hours

9. Results: Role Play

10. Results: Satisfaction

11. Results: Red Flags

12. Results: Chart Review • Charts reviewed • 28 reviewed • 34 not found • 28 mismatched name/chart number • Results • 20 (71%) red flags (earlier visits) • 6 (20%) CHW-instructed earlier visits • Key indicators: • Cough >2 weeks • Adherence

13. Discussion • Technology • Minimal training requirements • Quickly attained and maintained • Good connection and server functionality • Acceptance and satisfaction • Clinical significance • High numbers of red flags • CHWs identify critical issues clinicians may not • Limitations and next steps • Small sample size, short follow-up period • Inability to locate many charts • Next steps: Push technology to link to clinicians

14. Thank You • University of Pennsylvania • Penn CFAR • Greg Bisson, MD MSCE • Nairobi, Kenya • KhouShong MPH • DonataMuthoni • Josephine Mwagiru • IT team • Debbie Theobald • Adam Kundishora