TABLE OF CONTENTS
DECLARATION………………………………………………………………………………………… ii
DEDICATION…………………………………………………………………………………………… iii
ACKNOWLEDGMENT…………………………………………………………………………….. iv
TABLE OF CONTENTS…………………………………………………………………………….. v
LIST OF TABLES……………………………………………………………………………………… ix
LIST OF FIGURES…………………………………………………………………………………….. x
OPERATIONAL DEFINITION OF TERMS……………………………………………… xi
ABBREVIATIONS AND ACRONYMNS…………………………………………………. xiv
ABSTRACT……………………………………………………………………………………………… xvi
CHAPTER ONE: INTRODUCTION………………………………………………………….. 1
- Background to the study……………………………………………………………………. 1
CHAPTER TWO: LITERATURE REVIEW…………………………………………….. 10
2. 1 Introduction……………………………………………………………………………………. 10
- Overview of HIV Testing and Counselling, access to Care and Treatment 10
CHAPTER THREE: MATERIALS AND METHODS………………………………. 21
- Research Design………………………………………………………………………………. 21
CHAPTER FOUR: RESULTS…………………………………………………………………… 26
- Introduction…………………………………………………………………………………….. 26
- Referral practices by HTC site…………………………………………………………… 36
- Documentation………………………………………………………………………………. 36
- Referral facilitation activities by HTC type…………………………………………. 42
- Referral practices by HTC site…………………………………………………………… 36
4.5.1.1Referral for emergency cases…………………………………………………………. 42
CHAPTER FIVE: DISCUSSION, CONCLUSION AND RECOMMENDATIONS……………………………………………………………………………. 47
5.3.3 Referral facilitation activities of HTC providers in Nairobi…………………. 51
REFERENCES…………………………………………………………………………………………. 56
APPENDICES…………………………………………………………………………………………… 62
Appendix I: Map of Nairobi……………………………………………………………………. 62
Appendix II: Questionnaire…………………………………………………………………….. 63
Appendix V: Kenyatta National Hospital Ethics Committee Approval………… 74
Appendix VI: NASCOP Research Approval…………………………………………….. 75
LIST OF TABLES
Table 4.1Characteristics of the HTC sites…………………………………………………. 27
Table 4.2 Cross classification of possession of national guidelines for HTC and type of HTC site……………………………………………………………………………………. 32
Table 4.3Crosstab of possession of the national guidelines and accreditation by NASCOP…………………………………………………………………………………………….. 33
Table 4.4 Number of clients tested and HIV positivity………………………………. 34
Table 4.5 Crosstab of referrals by type of HTC site…………………………………… 35
Table 4.6 Crosstab of HTC site type and documented referral system…………. 38
Table 4.7 – Formal working relationships with collaborators……………………….. 40
Table 4.8 – Frequency of meetings with collaborators………………………………… 40
Table 4.9–Cross tab of the HTC site type and designation of referral manager 42 Table 4.10 – Accompaniment of emergency cases to referral point………………. 43
Table 4.11 – Provision of transport to referred HIV positive clients…………….. 44
Table 4.12 – Provision of bus fare to referral point…………………………………….. 44
Table 4.13 – Factors affecting effectiveness of referrals…………………………….. 46
LIST OF FIGURES
Figure 4.1: Type of HTC site………………………………………………………………….. 29
Figure 4.2 – Services provided by HTC site……………………………………………… 30
Figure 4.3 – Types of HTC services………………………………………………………….. 31
Figure 4.4 – Possession of the national guidelines for HTC…………………………. 31
Figure 4.5 – Last accreditation by NASCOP……………………………………………. 33
Figure 4.6 – Types of referral documents………………………………………………….. 36
Figure 4.7 – Referral documentation……………………………………………………….. 37
Figure 4.8- Name based or anonymous referrals………………………………………… 37
Figure 4.9 – Documented referral system…………………………………………………. 38
Figure 4.10 – Sites with list of collaborators……………………………………………… 39
Figure 4.11 – Ways of following up referrals……………………………………………. 41
Figure 4.12 – Designation of referral managers…………………………………………. 41
Figure 4.13 – Sites that had conducted emergency referrals……………………….. 42
Figure 4.14 – Communication with referral point………………………………………. 45
OPERATIONAL DEFINITION OF TERMS
Client initiated HTC : This refers to a situation whereby an individual,
couple or group actively seeks out HIV testing and counselling at a site where these services are provided and/or accessible (NASCOP, 2008).
HIV testing services (HTS): This refers to the full range of services that a client is
offered together with HIV testing, including pre and post-test counselling; linkage to appropriate HIV prevention, care and treatment services and other clinical support services; and coordination with laboratory services to support quality assurance and delivery of correct results (NASCOP, 2015).
Integrated HTC sites: These are HTC sites that are co-located on the grounds
of a health facility such as a hospital or a health clinic. The sole function of an integrated HTC centre is the provision of HTC services; other health services are generally not offered, though some related services such as family planning (FP) may be offered. The integrated HTC site may be a separate facility on the grounds of a functioning health facility, or it may be attached to the health facility such as a group of rooms in a specific ward (NASCOP, 2008).
Initiating facility : An organization, service, or community unit that
initiates a referral process by preparingan outward referral to communicate the client’s condition and
status; an initiating facility is also known as a “referring facility”(MOH, 2014).
Referral : A referral, in the context of HIV, is the process by
which immediate client needs for comprehensive HIV care and supportive services are assessed and clients helped to gain access to services, such as setting up appointments or giving directions to facilities (FHI, 2005).
Referral system : This is defined as a comprehensive health care system
used to manage client health care needs by referring clients from an initiating facility to an organization, service or community unit that can better provide the level of care needed (MOH, 2014).
Provider initiated HTC: This refers to a situation in which the HTC service
provider offers an HIV test to a client or patient regardless of their reason for attending the facility. This makes HTC part of routine care in health facilities in Kenya (NASCOP, 2008).
Referral facilitation activities: Actions carried out by HTC service providers to
ease client referrals from HTC site to HIV care and treatment sites (NASCOP, 2008).
Referral practices : Actions and tools used during the process of helping a
client gain access to services not provided by the HTC site such as use of standard forms to document referrals, having a list of service providers within the catchments area who can provide additional services to HIV positive clients and establishing formal working relationships with referral network partners, among others (MOH, 2014).
Stand-alone HTC sites: These are HTC sites within the community that are not
attached to other specific health services. Generally, these sites are operated by non-governmental organisations (NGOs), faith-based organisations (FBOs), or other community-based organisations (CBOs), though the Government of Kenya (GoK) does provide support to some stand-alone HTC sites (NASCOP, 2008).
Receiving facility: An organization, service, or community unit that
accepts a referred client or specimen from an initiating facility (MOH, 2014)
ABBREVIATIONS AND ACRONYMNS
| AIDS | Acquired Immune Deficiency Syndrome |
| AMNC | Australian Nursing and Midwifery Council |
| ART | Antiretroviral Therapy |
| ARV | Antiretroviral |
| CBO | Community Based Organization |
| CDC | Centre for Disease Control and Prevention |
| CRNBC | College of Registered Nurses British Colombia |
| DASCO | District AIDS and STIs Coordinator |
| FBO | Faith Based Organization |
| FHI | Family Health International |
| GOK | Government of Kenya |
| GST | General System Theory |
| HBTC | Home Based Testing and Counselling |
| HIV | Human Immunodeficiency Virus |
| HTC | HIV Testing and Counselling |
| IMF | International Monetary Fund |
| KAIS | Kenya AIDS Indicator Survey |
| KASF | Kenya AIDS Strategic Framework |
| KNASP | Kenya National AIDS Strategic Plan |
| MDGs | Millennium Development Goals |
| MOH | Ministry of Health |
| MSM | Men who have sex with Men |
| NACC | National AIDS Control Council |
| NASCOP | National AIDS and STIs Control Programme |
| NGO | Non-Governmental Organization |
| OI | Opportunistic Infections |
| PITC | Provider Initiated Testing and Counselling |
| PMTCT | Prevention of Mother to Child Transmission |
| PwP | Prevention with Positives |
| SDGs | Sustainable Development Goals |
| SPSS | Statistical Package for Social Scientists |
| STI | Sexually Transmitted Infections |
| TB | Tuberculosis |
| USA | United States of America |
| VCT | Voluntary Counselling and Testing |
| WHO | World Health Organization |
ABSTRACT
Knowledge of one’s HIV status through HIV Testing and Counselling remains the first step towards HIV prevention, appropriate care, support and treatment services. The knowledge needs to be coupled with means ofaccessing and obtaining essential post test services including appropriate care and treatment for all individuals who test HIV positive. Through linkages with care, treatment and support programs, HTC is expected to contribute to lessening the impact of the HIV epidemic on children, adults, families and communities only if all clients who test HIV positive are offered and/or linkedto all the requisite prevention, care and treatment services. Therefore the aim of the study was toidentify frequency of referrals, referral practices and facilitation activities of HTC providers in Nairobi County for individuals who test HIV positive.The objectives of the study were to determine the frequency of referrals for HIV positive clients by type of HTC site, identify the referral practices by HTC type and establish referral facilitation activities for clients to test HIV positive by type of HTC type in Nairobi County. A cross-sectional comparative study design was employed. The study took a census approach and a total of 92 sites participated in the study.A structured questionnaire was administered to 92 authorized personnel at the HTC sites. The Statistical Package for Social Sciences version 22.0 was used for quantitative data analysis. Key variables of the study were cross tabulated with the main institutional variables and aggregates computed. The relationship between the HTC site type and thevaried referral practices and facilitation activities was assessed using the chi square test of association. The results were presented in form of tables, bar charts, and pie charts.Findings showed that 94% the sites referred all the clients who tested HIV positive. However, there was no association between type of HTC site and referrals (X2 = 0.0039, P =0.95). Majority of the sites had a documented referral system. Nevertheless, there was no relationship between the type of HTC site and a documented referral system (X2 = 0.432, P =1). Only 44% of the sites had conducted referrals for HIV positive clients considered to be emergency cases, with 45% reporting accompanying clients. None of the referral facilitation activities studied had an association with the type of HTC site. The study concluded that there are gaps in the frequency of referrals, referral practices and facilitation activities of HTC providers for clients who test HIV positive in Nairobi County. The study recommends actions for both policy and practice modifications. Inorder to increase frequency of referrals, NASCOP should institute compliance measures to ensure HTC providers adhere to policy requirements for referral and linkage of all individuals who test HIV positive. The HTC sites should institute review of frequency of referrals and institute corrective measures to ensure linkage of all individuals who test HIV positive. Inorder to enhance referral practices, the National AIDS and STIs Control Program should refine and disseminate standardized guidance on referral practices for HTC sites. HTC sites should adhere to standard documentation for referrals, institute formal collaborative relationships with referral network partners and designate staff to manage referrals and folow ups. Inorder to improve referral facilitation activities, NASCOP should refine and disseminate standard guidance on referral facilitation activities related to accompaniment, transportation and follow up for clients who test HIV positive. On the other hand HTC sites should establish site specific activities that will ensure accompaniment, provision of transport and/or bus fare and follow up to intensify linkage of individuals who test HIV positive and are regarded as emergency cases, into requisite HIV care and treatment services.
CHAPTER ONE: INTRODUCTION
Background to the study
The Human Immunodeficiency Virus (HIV) pandemic is one of the greatest global public health challenges (UNAIDS, 2016). While tremendous success has been registered internationally in the fight against HIV/AIDS in the past 15 years, emerging trends such as slow decline in new HIV infections among adults threaten to reverse the gains made (UNAIDS, 2016).Concerted efforts have been commended for averting 8 million AIDS-related deaths, preventing 30 million new HIV infections and placing 15.8 million individuals on antiretroviral therapy (UNAIDS, 2015).Through the leadership of UNAIDS, the Fast -Track targets were established under the Sustainable Development Goals (SDG) -era to accelerate progress towards ending the epidemic by 2030 (UNAIDS, 2014).
It is estimated that globally, in 2017, a total of 36.9 million people were living with HIV and 1.8 million people became newly infected (UNAIDS, 2018). In Kenya, the first case of HIV was diagnosed in 1984 (NACC, 2005). Since then, HIV spread rapidly in the 1990s impacting all levels of society (NASCOP, 2005). Recent estimates by the National AIDS Control Council (NACC) and the National AIDS and STI Control Programme (NASCOP) indicate that 1.5 million people are living with HIV in Kenya by the end of 2015 (NACC &NASCOP, 2016).Further, the country has an average 5.9% adult HIV prevalence rate and an estimated 71,034 new infections (Ibid).
The government of Kenya declared HIV a national disaster in 1999 and subsequently established the NACC to coordinate a multi-sectoral national response (NASCOP, 2014).
NACC facilitated the development of the Kenya National AIDS Strategic Plans (KNASP) I, II and III and the current Kenya AIDS Strategic Framework (KASF) to provide a multisectoral response for addressing HIV and AIDS in alignment to the Constitution of Kenya.
The World Health Organization (WHO) recognizes HIV testing and counselling (HTC) as a key intervention for expanding access to HIV prevention, care and treatment (WHO, 2009). In Kenya as in other countries, HTC is considered central to all HIV programs because it is recognized as the main entry point into HIV prevention, care, support and treatment services (NASCOP, 2015).
The national guidelines for HTC in Kenya stipulate the three primary components of HTC including the pre-test, the HIV test and the post-test session; these elements constitute the minimum service package of HTC (NASCOP, 2015). The guidelines emphasise the need for provision of referrals to appropriate follow up services, which should be provided to the clients during post-test counselling (Ibid). Specific referral requirements indicated in the guidelines include: having a directory of all available HIV/AIDS services in the vicinity for referral of clients and patients; having standardised referral forms; use of name-based referrals to facilitate referral and follow up; referral of clients who present with specific diseases and conditions for appropriate services such as tuberculosis, prevention of mother to child
transmission (PMTCT), management of sexually transmitted infections (STIs) or comprehensive care; and, referral of HIV positive clients and patients for additional counselling services when appropriate.
In addition to the national HTC guidelines, both the WHO and NASCOP require that HIV positive clients be provided with the following services either by referral or direct service provision: HIV literacy and psychosocial support; clinical assessment; management of opportunistic infections (OIs); provision of co-trimoxazole; Antiretroviral therapy (ART); prevention with positives (PwP) interventions; condoms; PMTCT; screening for tuberculosis; malaria prevention and treatment; management of STIs; palliative care and symptom management; and, safe drinking water interventions (NASCOP, 2015; WHO, 2009).
In addition, the Kenya Ministry of Health developed a referral strategy, to provide guidance on and ensure efficient linkages cross all levels of care within the health service delivery system (MOH, 2008). The strategy outlines how to build an effective referral system (Ibid).
Statement of the Problem
Kenya is among the countries that have considerably expanded HTC by adoption of new approaches which encourage its uptake (WHO, 2009). Consequently, more people are being tested for HIV, which makes follow up to ensure complete referrals critical for those found to be HIV positive.
The 2007 Kenya AIDS Indicator Survey (KAIS) showed that nationwide, 1.42 million people were HIV infected at the time (NASCOP, 2009). However, the survey indicated that only 12.1% of all HIV–infected adults were on daily cotrimoxazole. Further, of all HIV infected adults who were eligible for Antiretroviral Therapy (ART), 59.5% were not taking daily Antiretrovirals (ARVs) (Ibid). The disparity between individuals who had been tested positive for HIV and those on HIV care and treatment points to gaps in referrals and linkages between HTC and HIV care and treatment services.
The national guidelines for HIV testing services (NASCOP, 2015) and The Referral Strategy (MOH, 2008) require referral of individuals who test HIV positive to appropriate follow up services. However, there is a paucity of data on the frequency of referrals, actual referral practices and facilitation activities of HTC providers for clients who test HIV positive in Kenya, hence the need to conduct the study in Nairobi County.
Justification
There is need to conduct this study because understanding the frequency of referrals for HIV positive clients, referral practices, referral facilitation activities that deter or enable referrals shall contribute to the establishment and/or strengthening of referral mechanisms. The findings will enable re -design of referral mechanisms to facilitate higher rates of entry into critical care and treatment by clients who test HIV positive. Consequently, with timely access to lifesaving antiretroviral therapy there will be a reduction in HIV-related mortality and morbidity.
