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"They just come, pick and go." The Acceptability of Integrated Medication Adherence Clubs for HIV and Non Communicable Disease (NCD) Patients in Kibera, Kenya

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      Abstract

      IntroductionThe number of people on antiretroviral therapy (ART) for the long-term management of HIV in low- and middle-income countries (LMICs) is continuing to increase, along with the prevalence of Non-Communicable Diseases (NCDs). The need to provide large volumes of HIV patients with ART has led to significant adaptations in how medication is delivered, but access to NCD care remains limited in many contexts. Medication Adherence Clubs (MACs) were established in Kibera, Kenya to address the large numbers of patients requiring chronic HIV and/or NCD care. Stable NCD and HIV patients can now collect their chronic medication every three months through a club, rather than through individual clinic appointments.MethodologyWe conducted a qualitative research study to assess patient and health-care worker perceptions and experiences of MACs in the urban informal settlement of Kibera, Kenya. A total of 106 patients (with HIV and/or other NCDs) and health-care workers were purposively sampled and included in the study. Ten focus groups and 19 in-depth interviews were conducted and 15 sessions of participant observation were carried out at the clinic where the MACs took place. Thematic data analysis was conducted using NVivo software, and coding focussed on people’s experiences of MACs, the challenges they faced and their perceptions about models of care for chronic conditions.ResultsMACs were considered acceptable to patients and health-care workers because they saved time, prevented unnecessary queues in the clinic and provided people with health education and group support whilst they collected their medication. Some patients and health-care workers felt that MACs reduced stigma for HIV positive patients by treating HIV as any other chronic condition. Staff and patients reported challenges recruiting patients into MACs, including patients not fully understanding the eligibility criteria for the clubs. There were also some practical challenges during the implementation of the clubs, but MACs have shown that it is possible to learn from ART provision and enable stable HIV and NCD patients to collect chronic medication together in a group.ConclusionsExtending models of care previously only offered to HIV-positive cohorts to NCD patients can help to de-stigmatise HIV, allow for the efficient clinical management of co-morbidities and enable patients to benefit from peer support. Through MACs, we have demonstrated that an integrated approach to providing medication for chronic diseases including HIV can be implemented in resource-poor settings and could thus be rolled out in other similar contexts.

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      An overview of cardiovascular risk factor burden in sub-Saharan African countries: a socio-cultural perspective

      Background Sub-Saharan African (SSA) countries are currently experiencing one of the most rapid epidemiological transitions characterized by increasing urbanization and changing lifestyle factors. This has resulted in an increase in the incidence of non-communicable diseases, especially cardiovascular disease (CVD). This double burden of communicable and chronic non-communicable diseases has long-term public health impact as it undermines healthcare systems. Purpose The purpose of this paper is to explore the socio-cultural context of CVD risk prevention and treatment in sub-Saharan Africa. We discuss risk factors specific to the SSA context, including poverty, urbanization, developing healthcare systems, traditional healing, lifestyle and socio-cultural factors. Methodology We conducted a search on African Journals On-Line, Medline, PubMed, and PsycINFO databases using combinations of the key country/geographic terms, disease and risk factor specific terms such as "diabetes and Congo" and "hypertension and Nigeria". Research articles on clinical trials were excluded from this overview. Contrarily, articles that reported prevalence and incidence data on CVD risk and/or articles that report on CVD risk-related beliefs and behaviors were included. Both qualitative and quantitative articles were included. Results The epidemic of CVD in SSA is driven by multiple factors working collectively. Lifestyle factors such as diet, exercise and smoking contribute to the increasing rates of CVD in SSA. Some lifestyle factors are considered gendered in that some are salient for women and others for men. For instance, obesity is a predominant risk factor for women compared to men, but smoking still remains mostly a risk factor for men. Additionally, structural and system level issues such as lack of infrastructure for healthcare, urbanization, poverty and lack of government programs also drive this epidemic and hampers proper prevention, surveillance and treatment efforts. Conclusion Using an African-centered cultural framework, the PEN3 model, we explore future directions and efforts to address the epidemic of CVD risk in SSA.
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        Why reinvent the wheel? Leveraging the lessons of HIV scale-up to confront non-communicable diseases.

        The dramatic scale-up of HIV services in lower-income countries has led to the development of service delivery models reflecting the specific characteristics of HIV and its treatment as well as local contexts and cultures. Given the shared barriers and challenges faced by health programmes in lower-income countries, many of the implementation approaches developed for HIV programmes have the potential to contribute to the continuity care framework needed to address non-communicable diseases (NCDs) in resource-limited settings. HIV programmes are, in fact, the first large-scale chronic disease programmes in many countries, offering local and effective tools, models and approaches that can be replicated, adapted and expanded. As such, they might be used to 'jumpstart' the development of initiatives to provide prevention, care and treatment services for NCDs and other chronic conditions.
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          A population-based survey of prevalence of diabetes and correlates in an urban slum community in Nairobi, Kenya

          Background Urban slum populations in Africa continue to grow faster than national populations. Health strategies that focus on non-communicable diseases (NCD) in this segment of the population are generally lacking. We determined the prevalence of diabetes and associated cardiovascular disease (CVD) risk factors correlates in Kibera, Nairobi’s largest slum. Methods We conducted a population-based household survey utilising cluster sampling with probability proportional to size. Households were selected using a random walk method and consenting residents aged 18 years and above were recruited. The WHO STEPS instrument was administered. A random capillary blood sugar (RCBS) was obtained; known persons with diabetes and subjects with a RCBS >11.1 had an 8 hours fasting blood sugar (FBS) drawn. Diabetes was defined as a RCBS of ≥ 11.1 mmol/l and a FBS of ≥ 7.0 mmol/l, or a prior diagnosis or receiving diabetes drug treatment. Results Out of 2061 enrolled; 50.9% were males, mean age was 33.4 years and 87% had a minimum of primary education. Only 10.6% had ever had a blood sugar measurement. Age adjusted prevalence of diabetes was 5.3% (95% CI 4.2-6.4) and prevalence increased with age peaking at 10.5% (95% CI 6.8-14.3%) in the 45–54 year age category. Diabetes mellitus (DM) correlates were: 13.1% smoking, 74.9% alcohol consumption, 75.7% high level of physical activity; 16.3% obese and 29% overweight with higher rates in women. Among persons with diabetes the odds of obesity, elevated waist circumference and hypertension were three, two and three fold respectively compared to those without diabetes. Cardiovascular risk factors among subjects with diabetes were high and mirrored that of the entire sample; however they had a significantly higher use of tobacco. Conclusions This previously unstudied urban slum has a high prevalence of DM yet low screening rates. Key correlates include cigarette smoking and high alcohol consumption. However high levels of physical activity were also reported. Findings have important implications for NCD prevention and care. For this rapidly growing youthful urban slum population policy makers need to focus their attention on strategies that address not just communicable diseases but non communicable diseases as well.
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            Author and article information

            Affiliations
            [1 ]Médecins Sans Frontières Southern Africa Medical Unit, Cape Town, South Africa
            [2 ]Division of Social and Behavioural Sciences, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
            [3 ]Medical Department, Operational Centre Brussels, Médecins Sans Frontières Belgium, Brussels, Belgium
            [4 ]Médecins Sans Frontières, Nairobi, Kenya
            University of Pittsburgh, UNITED STATES
            Author notes

            Competing Interests: The authors have declared that no competing interests exist.

            • Conceptualization: HB SB WE JE.

            • Formal analysis: EV.

            • Methodology: EV SB HB.

            • Project administration: KK.

            • Writing – original draft: EV JE SB HB.

            • Writing – review & editing: WE KK.

            Contributors
            Role: Editor
            Journal
            PLoS One
            PLoS ONE
            plos
            plosone
            PLoS ONE
            Public Library of Science (San Francisco, CA USA )
            1932-6203
            20 October 2016
            2016
            : 11
            : 10
            27764128
            5072644
            10.1371/journal.pone.0164634
            PONE-D-16-13928
            (Editor)
            © 2016 Venables et al

            This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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            Funding
            The authors received no specific funding for this work.
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            Biology and Life Sciences
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            Microbial Pathogens
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            Due to ethical restrictions regarding the privacy and confidentiality of participants, data are available upon request. Requests may be sent to the corresponding author (emilie. venables@ 123456brussels.msf.org ).

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