Browsing by Author "Muli, Lindah"

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    Implementing WHO Differentiated Service Delivery Model for Pregnant and Breastfeeding Women and Infants Living with HIV: Insights from Kenyan Healthcare Providers
    (Global Health and Education Projects, 2025-01-22) Humphrey, John; Carlucci, James G.; Wanjama, Esther Karen; Naanyu, Violet; Muli, Lindah; Alera, Joy Marsha; Were, Edwin; McGuire, Alan; Nyandiko, Winstone; Zimet, Gregory; Jerono Songok, Julia; Wools-Kaloustian, Kara; Medicine, School of Medicine
    Background and Objective:: Differentiated service delivery (DSD) is a strategy endorsed by the World Health Organization that simplifies and adapts human immunodeficiency (HIV) services to meet the needs of people living with HIV (PLHIV) while reducing unnecessary health system burdens. DSD for PLHIV has been widely adopted in sub-Saharan Africa, but DSD for women and infants enrolled in prevention of mother-to-child HIV transmission (PMTCT) services is lacking. Methods:: We conducted in-depth interviews with healthcare providers (i.e., clinicians, nurses, and mentor mothers) in antenatal and postnatal clinics at two facilities affiliated with the Academic Model Providing Access to Healthcare (AMPATH) in Kenya to explore perspectives on the adaptation of DSD for PMTCT. Providers were recruited in person at each facility. Interview guides focused on their views on DSD implementation for PMTCT, characteristics of stable and unstable PMTCT clients, and strategies to improve PMTCT services. We used inductive coding with illustrative quotes to highlight emerging themes. Results:: 12 PMTCT providers (6 antenatal, 6 postnatal; 4 clinicians, 4 nurses, and 4 mentor mothers) were enrolled; 10 (83%) were female, with a median age of 40 years, and a median of 7 years of PMTCT experience. Providers held positive views about the potential benefits of DSD for PMTCT but expressed concern about reducing service intensity during pregnancy/breastfeeding. Providers also suggested specific criteria defining stable PMTCT clients beyond those used for non-pregnant PLHIV, such as having no pregnancy complications, psychosocial or socioeconomic barriers, or breastfed infants. Conclusion and Global Health Implications:: Filling the gap in DSD guidance for this population will require adaptations to the DSD model that are responsive to providers’ concerns and the unique aspects of the pregnancy-postpartum service continuum, which may vary across settings based on contextual and client-level factors. Such nuanced guidance will need to remain clear and simple to implement to ensure implementation fidelity at scale.
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    Outcomes After Loss to Follow-Up for Pregnant and Postpartum Women Living With HIV and Their Children in Kenya: A Prospective Cohort Study
    (Wolters Kluwer, 2024) Humphrey, John; Kipchumba, Bett; Alera, Marsha; Sang, Edwin; Musick, Beverly; Muli, Lindah; Kipsang, Justin; Songok, Julia; Yiannoutsos, Constantin; Wools-Kaloustian, Kara; Medicine, School of Medicine
    Background: Many prevention of vertical transmission (PVT) studies assess outcomes within 12 months postpartum and exclude those lost to follow-up (LTFU), potentially biasing outcomes toward those retained in care. Setting: Five public facilities in western Kenya. Methods: We recruited women living with HIV (WLH) ≥18 years enrolled in antenatal clinic (ANC). WLH retained in care (RW) were recruited during pregnancy and followed with their children through 6 months postpartum; WLH LTFU (LW, last visit >90 days) after ANC enrollment and ≤6 months postpartum were recruited through community tracing. Recontact at 3 years was attempted for all participants. Primary outcomes were retention and child HIV-free survival. Generalized linear regression was used to estimated risk ratios (RRs) for associations with becoming LTFU by 6 months postpartum, adjusting for age, education, facility, travel time to facility, gravidity, income, and new vs. known HIV positive at ANC enrollment. Results: Three hundred thirty-three WLH (222 RW, 111 LW) were recruited from 2018 to 2019. More LW versus RW were newly diagnosed with HIV at ANC enrollment (49.6% vs. 23.9%) and not virally suppressed at study enrollment (40.9% vs. 7.7%). 6-month HIV-free survival was lower for children of LW (87.9%) versus RW (98.7%). At 3 years, 230 WLH were retained in care (including 51 previously LTFU before 6 months), 30 transferred, 70 LTFU, and 3 deceased. 3-year child HIV-free survival was 81.9% (92.0% for children of RW, 58.6% for LW), 3.7% were living with HIV, 3.7% deceased, and 10.8% had unknown HIV/vital status. Being newly diagnosed with HIV at ANC enrollment was the only factor associated with becoming LTFU (aRR 1.21, 95% CI: 1.11 to 1.31). Conclusions: Outcomes among those LTFU were worse than those retained in care, underscoring the importance of retention in PVT services. Some, but not all, LW re-engaged in care by 3 years, suggesting the need for PVT services must better address the barriers and transitions women experience during pregnancy and postpartum.
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    Preferences of Pregnant and Postpartum Women for Differentiated Service Delivery in Kenya
    (Wolters Kluwer, 2023) Humphrey, John; Wanjama, Esther; Carlucci, James G.; Naanyu, Violet; Were, Edwin; Muli, Lindah; Alera, Marsha; McGuire, Alan; Nyandiko, Winstone; Songok, Julia; Wools-Kaloustian, Kara; Zimet, Gregory; Medicine, School of Medicine
    Background: Differentiated service delivery models are implemented by HIV care programs globally, but models for pregnant and postpartum women living with HIV (PPWH) are lacking. We conducted a discrete choice experiment to determine women's preferences for differentiated service delivery. Setting: Five public health facilities in western Kenya. Methods: PPWH were enrolled from April to December 2022 and asked to choose between pairs of hypothetical clinics that differed across 5 attributes: clinic visit frequency during pregnancy (monthly vs. every 2 months), postpartum visit frequency (monthly vs. only with routine infant immunizations), seeing a mentor mother (each visit vs. as needed), seeing a clinician (each visit vs. as needed), and basic consultation cost (0, 50, or 100 Kenya Shillings [KSh]). We used multinomial logit modeling to determine the relative effects (β) of each attribute on clinic choice. Results: Among 250 PPWH (median age 31 years, 42% pregnant, 58% postpartum, 20% with a gap in care), preferences were for pregnancy visits every 2 months (β = 0.15), postpartum visits with infant immunizations (β = 0.36), seeing a mentor mother and clinician each visit (β = 0.05 and 0.08, respectively), and 0 KSh cost (β = 0.39). Preferences were similar when stratified by age, pregnancy, and retention status. At the same cost, predicted market choice for a clinic model with fewer pregnant/postpartum visits was 75% versus 25% for the standard of care (ie, monthly visits during pregnancy/postpartum). Conclusion: PPWH prefer fewer clinic visits than currently provided within the standard of care in Kenya, supporting the need for implementation of differentiated service delivery for this population.
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    Understanding Women’s Preferences for Prevention of Mother-to- Child HIV Transmission Services in Kenya
    (Global Health and Education Projects, 2024-05-17) Humphrey, John; Wanjama, Esther; Carlucci, James G.; Naanyu, Violet; Muli, Lindah; Were, Edwin; McGuire, Alan; Nyandiko, Winstone M.; Songok, Julia; Zimet, Gregory; Wools-Kaloustian, Kara; Medicine, School of Medicine
    Background and objective: Understanding the preferences of women living with HIV (WLH) for the prevention of mother-to-child HIV transmission (PMTCT) services is important to ensure such services are person-centered. Methods: From April to December 2022, we surveyed pregnant and postpartum WLH enrolled at five health facilities in western Kenya to understand their preferences for PMTCT services. WLH were stratified based on the timing of HIV diagnosis: known HIV-positive (KHP; before antenatal clinic [ANC] enrollment), newly HIV-positive (NHP; on/after ANC enrollment). Multivariable logistic regression was used to determine associations between various service preferences and NHP (vs. KHP) status, controlling for age, facility, gravidity, retention status, and pregnancy status. Results: Among 250 participants (median age 31 years, 31% NHP, 69% KHP), 93% preferred integrated versus non-integrated HIV and maternal-child health (MCH) services; 37% preferred male partners attend at least one ANC appointment (vs. no attendance/no preference); 54% preferred support groups (vs. no groups; 96% preferred facility - over community-based groups); and, preferences for groups was lower among NHP (42%) versus KHP (60%). NHP had lower odds of preferring support groups versus KHP (aOR 0.45, 95% CI 0.25-0.82), but not the other services. Conclusion and global health implications: Integrated services were highly preferred by WLH, supporting the current PMTCT service model in Kenya. Further research is needed to explore the implementation of facility-based support groups for WLH as well as the reasons underlying women's preferences.