Susan Njogo National AIDS/STI Control Program, Kenya

1. Improving Appointment Keeping and Adherence Monitoring In ART Facilities in Kenya: Views of Providers and Patients Susan Njogo National AIDS/STI Control Program, Kenya

2. Background • Antiretroviral Therapy (ART) program in Kenya started in 2003 in the public sector. • Scale-up of patients on ART from 10,000 patient in 2004 to over 500,000 by Sept 2011 (adults: 461,000, children: 43,000) • Over 1100 health facilities offering ART (level 2 to 6) • Accessibility to ART has been achieved through decentralization of HIV services to all levels of health care. • Improving the quality of care is a priority for the National HIV/AIDS & STI Control Program (NASCOP). • Majority of the health facility have manual data management system

3. Problem statement • Adherence monitoring and tracking appointment keeping for patients on ART is a challenge due to: • large patients load • lack of efficient system to track patients • weak community linkages • lack of adherence monitoring tools • shortage of health workers • Inadequacy of skills • This has led to lack or inadequate ways of identifying missed appointments resulting to no or delayed tracking of patients missing appointments

4. Study setting (1) • This was an intervention study with staggered implementation that employed interrupted time series analysis • This was a composite health systems strengthening intervention employing both quantitative and qualitative methods of data collection.

5. Study setting (2) • Interventions comprised implementation of • Alongitudinal patient clinic appointment register for tracking patient clinic attendance • Modifying national routine patient monitoring card (MoH-257) • Targeted training of health service provider on basic adherence concepts including use of data for decision making. • Making supervisory visits to support the facility teams with implementation process. • The study was implemented over a one year period with a pre-intervention phase, intervention phase and a post-intervention phase.

6. Study aim • The goal of the study was to evaluate the effectiveness of a health systems intervention aimed at improving adherence performance in health facilities providing ART in Kenya.

8. Methods Purposive sampling, focused on key actors to maximize diversity of views. • 30 in-depth interviews with health providers (from the six facilities) performing key functions around patient adherence counseling and monitoring. • Patients on ARVs • In-depth interviews with adherent (six) and non-adherent (six) patients • Focus group sessions (six) with members of a patient support groups.

9. Results (1) • The appointment diary was perceived to be useful for monitoring of patients appointment keeping behaviour. • “ since we started using the diary, we have been able to monitor the clients and we know when to expect the clients to come so that we can monitor and now when each is coming and also the number of clients we expect in a day” Clinician • Standardization of question on patients self-report was reported to be more accurate. • Revised question: Have you missed any medicine in the last 3 days? (ARVs, Cotrimoxazole, Fluconazole) • Facilities reported to have generated actual retention rates “…. it was an eye opener for us. ….we used to work blindly. …….from the time we started the study in April last year as from May up to Sept , I discovered that there was a drop in clinic attendance of clients from 75% to 51% a whole 24.5%” clinician

10. Results (2) • Factors perceived to lead to missed appointments by patients included clinic operation days and hours, lack of transport, confidentiality, non-integrated HIV services, nondisclosure and stigma. • Staff reported a considerable increase in workload mainly due to staff shortage, however, they considered this extra workload manageable.

11. Policy implication & Conclusion (1) • The appointment keeping diary is a useful tool in monitoring adherence and assists in prompt identification of defaulters and hence timely tracking. • This outcome may inform policy on quality of care improvement, specifically adherence and appointment keeping monitoring.

12. Policy implication & Conclusion (2) • Considerations should be made for national roll out to health facilities providing ART • Monitoring of appointment keeping supports the identification of patients requiring adherence reinforcement as well as strengthening the adherence monitoring practices and systems at facility level.

13. Lessons learnt • A longitudinal register is key to adherence monitoring at facility level. • Strengthening ability to generate and share data for decision making is key to improving facility performance • A working health system is a motivating factor for service providers to improve patient management.

14. Acknowledgements National AIDS/STI Control Program (NASCOP), Kenya Participating Health facilities in Kenya Division of Global Health (IHCAR), KarolinskaInstitutet, Sweden Management Sciences for Health/Strengthening Pharmaceutical Systems Harvard Medical School and Harvard Pilgrim Health Care, USA; INRUD-IAA SIDA USAID