Family model of HIV care and treatment: a retrospective study in Kenya

Journal of the International AIDS Society Family model of HIV care and treatment: a retrospective study in Kenya Jayne Lewis Kulzer 0 Jeremy A Penner jeremy@transformation- 0 Reson Marima 0 Patrick Oyaro 0 Arbogast O Oyanga 0 Starley B Shade 0 Cinthia C Blat 0 Lennah Nyabiage Christina W Mwachari 0 Hellen C Muttai Elizabeth A Bukusi 0 Craig R Cohen 0 0 Family AIDS Care and Education Services (FACES), Research Care and Training Program, Centre for Microbiology Research, Kenya Medical Research Institute , Kisumu , Kenya Background: Nyanza Province, Kenya, had the highest HIV prevalence in the country at 14.9% in 2007, more than twice the national HIV prevalence of 7.1%. Only 16% of HIV-infected adults in the country accurately knew their HIV status. Targeted strategies to reach and test individuals are urgently needed to curb the HIV epidemic. The family unit is one important portal. Methods: A family model of care was designed to build on the strengths of Kenyan families. Providers use a family information table (FIT) to guide index patients through the steps of identifying family members at HIV risk, address disclosure, facilitate family testing, and work to enrol HIV-positive members and to prevent new infections. Comprehensive family-centred clinical services are built around these steps. To assess the approach, a retrospective study of patients receiving HIV care between September 2007 and September 2009 at Lumumba Health Centre in Kisumu was conducted. A random sample of FITs was examined to assess family reach. Results: Through the family model of care, for each index patient, approximately 2.5 family members at risk were identified and 1.6 family members were tested. The approach was instrumental in reaching children; 61% of family members identified and tested were children. The approach also led to identifying and enrolling a high proportion of HIV- positive partners among those tested: 71% and 89%, respectively. Conclusions: The family model of care is a feasible approach to broaden HIV case detection and service reach. The approach can be adapted for the local context and should continue to utilize index patient linkages, FIT adaption, and innovative methods to package services for families in a manner that builds on family support and enhances patient care and prevention efforts. Further efforts are needed to increase family member engagement. - Background Nyanza Province had the highest HIV prevalence in Kenya at 14.9% in 2007, more than twice the national HIV prevalence of 7.1% [1]. Despite this high HIV prevalence, the majority of Kenyans were unaware of their status: only one-third of adults had been tested for HIV and just 16% of HIV-infected adults accurately knew their HIV status [1]. Stigma, denial and fear of rejection continue to impede HIV testing, and along with limited access to care and treatment services, act as barriers to engaging in medical care for those who test HIV positive [2-5]. Children are particularly vulnerable to HIV infection if their mothers are HIV-infected, and their HIV status often goes undetected; there are an estimated 184,052 HIV-infected children in Kenya, and 117,000 of them urgently need highly active antiretroviral therapy (HAART), yet only 24% have received HAART [6]. The urgency of reaching these remaining children is demonstrated by studies showing that 50% of children born with HIV will die before their second birthday if left untreated [7-9]. Targeted strategies to reach and identify untested individuals are critically needed to curb the HIV epidemic in Kenya. The family unit is one important portal. For each HIV-positive index patient, one or more family members may be HIV positive or at high risk of HIV acquisition. Family members at risk in this context include sexual partners of index patients and the index patients children younger than 15 years with HIV vulnerability stemming from sexual contact and mother to child transmission, respectively. Reaching these vulnerable family members begins with disclosure of ones HIV status. Disclosure to partners facilitates discussions on HIV and raises partner awareness about their risk and need to test [4]. Disclosure also has important health benefits. It increases access to social support, fosters closer relationships with others, increases testing uptake, improves treatment adherence and retention, and reduces risk of HIV transmission to partners [4,5,10]. This prevention potential is considerable among couples: in Kenya, 45% of HIV-infected married people have HIV-negative partners [1]. Although disclosure brings many benefits, there are significant obstacles and risks involved. Fear of negative outcomes is the most common barrier to women disclosing, and women who disclose risk violence from a partner if appropriate support is not present [4,5,10]. A study in Kenya found that 28% of women feared rejection by their family if they disclosed and 32% feared it would lead to partner break up [4]. However, a study of disclosure findings from 15 studies (14 in sub-Saharan Africa, including three in Kenya) found that actual disclosure outcomes were far more positive than women anticipated: the majority of women received supportive reactions after disclosing [5]. One of the studies in Kenya reported that 94% of HIV-positive women feared their partners reactions, yet among women who disclosed to partners, 73% reported that partners were understanding [5]. Another study in Tanzania reported that 92% of women who disclosed remained in relationships that were intact [5]. The reason for this level of acceptance and support is not completely known; perhaps women had or were equipped with skills for safe disclosure. This is not to say that negative outcomes are not experienced. In a study conducted in Kenya among women who disclosed, 3.5% reported being physically assaulted and 3.5% were chased from their homes, while in Tanzania, 15% experienced violence from their partners [5]. Preventing negative and harmful consequences is critical to patient and family well-being. Unfortunately, gender-based violence in Kenya and other subSaharan African settings has not been well addressed by HIV programmes [10]. Once vulnerable family members are reached for HIV testing, the opportunity to immediately enrol those who are HIV positive into care is created. Patients who enter HIV care early, before developing symptomatic disease, have better outcomes [11]. Family member testing also creates the opportunity to engage the family in care and support for those who are HIV positive. If one family member is HIV infected, the entire family is affected and has to cope with the physical, emotional, social and economic consequences of HIV. The family can be an important source of support. Studies in sub-Saharan Africa have found that the support of the family contributes to healthy behaviours and that partner involvement is associated with positive outcomes for HIVinfected member(s) [2,4,5 (...truncated)