Abstract
Objectives
To assess the care of hypertension, diabetes mellitus and/or HIV patients enrolled into Medication Adherence Clubs (MACs).
Methods
Retrospective descriptive study was carried out using routinely collected programme data from a primary healthcare clinic at informal settlement in Nairobi, Kenya. All patients enrolled into MACs were selected for the study. MACs are nurse‐facilitated mixed groups of 25–35 stable hypertension, diabetes mellitus and/or HIV patients who met quarterly to confirm their clinical stability, have brief health discussions and receive medication. Clinical officer reviewed MACs yearly, when a patient developed complications or no longer met stable criteria.
Results
A total of 1432 patients were enrolled into 47 clubs with 109 sessions conducted between August 2013 and August 2014. There were 1020 (71%) HIV and 412 (29%) non‐communicable disease patients. Among those with NCD, 352 (85%) had hypertension and 60 (15%) had DM, while 12 had HIV concurrent with hypertension. A total of 2208 consultations were offloaded from regular clinic. During MAC attendance, blood pressure, weight and laboratory testing were completed correctly in 98–99% of consultations. Only 43 (2%) consultations required referral for clinical officer review before their routine yearly appointment. Loss to follow‐up from the MACs was 3.5%.
Conclusions
This study demonstrates the feasibility and early efficacy of MACs for mixed chronic disease in a resource‐limited setting. It supports burden reduction and flexibility of regular clinical review for stable patients. Further assessment regarding long‐term outcomes of this model should be completed to increase confidence for deployment in similar contexts.
Keywords: operational research, SORT IT, Hypertension, Diabetes Mellitus
Abstract
Objectifs
Evaluer la prise en charge de l'hypertension, du diabète sucré et/ou des patients VIH inscrits dans des Clubs d'Observance du Traitement (COT).
Méthodes
Etude descriptive, rétrospective, utilisant les données de programme, collectées en routine dans une clinique de soins de santé primaires dans des zones d'habitations informelles à Nairobi au Kenya. Tous les patients inscrits dans les COT ont été sélectionnés pour l’étude. Les COT sont des groupes mixtes de 25 à 35 patients avec une hypertension stable, un diabète sucré et/ou atteints du VIH, avec une guidance infirmière, qui se réunissent trimestriellement pour confirmer leur stabilité clinique, avoir de brèves discussions de santé et recevoir des médicaments. Un clinicien révise annuellement les COT et quand un patient a développé des complications ou ne répond plus aux critères de stabilité.
Résultats
Un total de 1432 patients ont été recrutés dans 47 clubs et 109 sessions ont été menées entre août 2013 et août 2014. Il y avait 1 020 (71%) patients VIH et 412 (29%) souffrant de maladies non transmissibles (MNT). Parmi ceux avec des MNT, 352 (85%) présentaient une hypertension et 60 (15%) avaient le diabète sucré, tandis que 12 avaient en même temps le VIH et l'hypertension. Au total 2208 consultations ont pu être déchargées de la clinique régulière. Au cours de la fréquentation des COT, la pression artérielle, le poids et les tests de laboratoire ont été effectués correctement dans 98 à 99% des consultations. Seuls 43 (2%) consultations ont nécessité un renvoi pour révision par le clinicien avant le rendez‐vous annuel de routine. La perte de suivi dans les COT était de 3,5%.
Conclusions
Cette étude démontre la faisabilité et l'efficacité précoce des COT pour les maladies chroniques mixtes dans un contexte à ressources limitées. Elle soutien la réduction de la charge et la flexibilité de l'examen clinique régulier pour les patients stables. Une évaluation supplémentaire des résultats à long terme de ce modèle devrait être effectuée afin d'accroître la confiance pour son déploiement dans des contextes similaires.
Keywords: recherche opérationnelle, SORT‐IT, hypertension, diabète sucré
Abstract
Objetivos
Evaluar la atención prestada a pacientes con hipertensión, diabetes mellitus y/o VIH participando en Clubs de Adherencia a la Medicación (CAMs).
Métodos
Estudio descriptivo, retrospectivo, utilizando datos del programa recogidos de forma rutinaria de una clínica de atención primaria en un asentamiento irregular en Nairobi‐Kenia. Todos los pacientes que participaban en CAMs fueron seleccionados para el estudio. Los CAMs son grupos mixtos, con enfermeras como facilitadoras, de entre 25–35 pacientes con hipertensión estable, diabetes mellitus y/o VIH, que se reunían cada dos semanas para confirmar su estabilidad clínica, tener una discusión corta sobre salud y recibir la medicación. Un sanitario revisaba los CAMs cada año, cuando un paciente desarrollaba complicaciones o cuando dejaba de cumplir con los criterios de estabilidad.
Resultados
1432 pacientes participaban en 47 clubs y se realizaron 109 sesiones entre Agosto del 2013 y Agosto del 2014. Había 1020 (71%) pacientes con HIV y 412 (29%) con enfermedades no contagiosas (ENC). Entre aquellos con ENC, 352 (85%) tenían hipertensión y 60 (15%) tenían DM, mientras que 12 tenían VIH concurrente con hipertensión. Se descargó a los centros sanitarios habituales de 2208 consultas. Durante la atención en los CAMs, se tomó la presión sanguínea, el peso y se realizaron las pruebas de laboratorio de forma correcta en un 98–99% de las consultas. Solo 43 (2%) consultas tuvieron que ser referidas para ser revisadas por un sanitario antes de la cita anual rutinaria. La pérdida durante el seguimiento de las CAMs era del 3.5%.
Conclusiones
Este estudio demuestra la viabilidad y la eficacia temprana de los CAMs en enfermedades crónicas mixtas, en lugares con recursos limitados. Apoya la reducción de la carga y la flexibilidad de la revisión clínica regular de pacientes estables. Se debería realizar una mayor evaluación sobre los resultados obtenidos a largo plazo con este modelo con el fin de aumentar la confianza para su implementación bajo contextos similares.
Introduction
The increasing burden of hypertension and diabetes mellitus, combined with a growing number of patients on antiretroviral therapy, has resulted in a large number of patients in need of chronic care, straining the healthcare system. Kibera is an urban, informal settlement in Nairobi, Kenya, with an estimated population of 240 000 (MSF internal report 2009 1). The prevalence of hypertension and diabetes mellitus is estimated at 12.3% and 5.3%, respectively 2, 3, 4; Ayah et al. 2013, Oti SO et al. 2013, Van de ViJver et al. 2013. The prevalence of HIV infection is estimated at 12.6% 5; Dalal W et al. 2013, compared to a national average of 5.6% (Kenya AIDS indicator survey 2012 6. In collaboration with the Kenya Ministry of Health, Médecins Sans Frontières Médecins Sans Frontières (MSF) 7; Sobry A et al. 2013, established HIV/Tuberculosis (TB) services within three comprehensive outpatient clinics in Kibera in 2003 and introduced hypertension and diabetes mellitus care in 2009.
Medication Adherence Clubs (MACs) have been developed in South Africa as a unique solution to managing stable patients with HIV where they shifted care from overburdened clinics to peer groups; MSF has demonstrated improved patient outcomes such as viral load suppression, medication adherence, less loss to follow‐up and reduced clinician workload 8, 9, 10 Wilkinson LS. 2013; Luque‐Fernandez MA et al. 2013; MSF ART adherence club report and tool kit. 2012. Subsequently, WHO has recommended the peer group treatment model as one way to decrease the cumulative workload of follow‐ups on healthcare providers and to improve patient outcomes in its 2013 HIV treatment guideline 11. Finding solutions that give long‐term, quality care to this ever‐increasing cohort are of importance in other low resource settings.
To address the increasing demand for follow‐up of non‐communicable diseases (NCDs), in 2013, the Kibera project adopted the HIV MACs model but implemented combined MACs for hypertension, diabetes mellitus and HIV patients. In Kibera, MACs are nurse‐facilitated groups of 25–35 stable hypertension, diabetes mellitus and HIV patients who meet quarterly to: (i) confirm their clinical stability, (ii) have a short health talk and (iii) receive pre‐packed medications. Routine patient follow‐up with clinical officers occurs yearly, when a patient develops complications or no longer meets the inclusion criteria. A rigorous literature search yielded no published studies describing the use of MACs for patients with multiple non‐communicable diseases.
This study assessed the care of hypertension, diabetes mellitus and HIV patients enrolled in MACs in the informal settlement of Kibera, Nairobi, Kenya from August 2013 to August 2014. Specifically, the study determined the proportions and characteristics of patients with NCDs and HIV infection, the number and proportion of hypertension, diabetes mellitus and HIV consultations where MACs protocols were followed, the number and proportion of MACs patients referred back to clinicians for complications or instability and the proportion of patients retained in MACs at three, six and twelve months.
Materials and methods
Study design and setting
This was a retrospective, descriptive study using routinely collected programme data in Kenya, an East African country with an approximate population of 39 million (Kenya population and housing census 2009 12. Nairobi, where Kibera is located, has an estimated population of three million (Kenya population and housing census 2009 12. The country is experiencing a rapidly growing burden of non‐communicable diseases (UNAIDS report‐2011 (13). The prevalence of diabetes mellitus in urban areas is almost twice the national average of 3.3% (First Kenya National forum on non‐communicable disease 2011 13. Overall, non‐communicable diseases cause over 50% of all hospital deaths and admissions (First Kenya National forum on NCD 2011 14. Of these deaths, 13% are due to cardiovascular diseases and 4% are due to complications of diabetes mellitus (First Kenya National Forum on NCD 2011 14. Of the 600 000 HIV‐infected people on ART, 75.4% have achieved viral suppression (Kenya AIDS indicator survey 2012 6), adding to the pool of chronic, stable patients.
Currently, Kenya Ministry of Health facilities offer hypertension and diabetes mellitus treatment only at the subcounty and county referral hospital levels and not at health centres or dispensaries. Most patients have to pay user fees to access non‐communicable disease services and medications. Despite decentralisation of HIV treatment where antiretroviral drugs are free, the majority of patients still pay out of pocket for treatment of opportunistic infections and laboratory tests other than those for routine HIV monitoring.
The study site was Kibera South Health Centre with an estimated catchment population of 88 000 (MSF Belgium Kibera; Annual report 2013 15). MSF, in collaboration with the Ministry of Health, is providing a comprehensive integrated primary health package that includes HIV, TB, non‐communicable disease, general outpatient department, nutrition, maternal child health and sexual‐ and gender‐based violence care at no cost to the client. There are 5500 active HIV patients (4700 on antiretroviral drugs, 80% with suppressed viral loads), 2200 hypertension and diabetes mellitus patients and approximately 200 patients who are comorbid with HIV and hypertension or diabetes mellitus (MSF Belgium Kibera; Annual report 2013 15).
The clinics are currently grappling with the challenge of large patient numbers requiring follow‐up, the majority of whom are stable. On average, there are approximately 3000 HIV and 1000 hypertension and diabetes mellitus combined consultations per month. There are approximately 100 new HIV and 70 new hypertension and diabetes mellitus patients per month. The same clinical officers and nurses who care for both HIV and non‐communicable disease patients also carry out outpatient department consultations averaging a total of 8000 consultations per month (MSF Belgium Kibera; Annual report 2013 15). This translates to approximately 45–50 consultations per day per clinician. The effect of this workload is an unacceptably long waiting time for patients at the clinics, averaging four to six hours (MSF Belgium Kibera; patient satisfaction survey 2012 16. The current loss to follow‐up rate for hypertension, diabetes mellitus and HIV cohorts, which is between 30 and 40% 7, (MSF Belgium Kibera; Annual report 2013 15), is possibly related to the long wait times and no available care on weekends.
Medication adherence clubs
HIV and non‐communicable disease patients were informed about the option of joining MACs through daily health talks in waiting bays, patient empowerment meetings and posters in the clinic. Patients were screened by clinicians during routine follow–up and if they met the inclusion criteria (see below) were offered the option of attending a MAC. Some patients proposed to join a MAC independently of clinician inquiry after sensitisation. Patients were provided signed informed consent before enrolment into the groups, acknowledging that there would be hypertension, diabetes mellitus and HIV patients in the MACs, but that diagnosis disclosure was voluntary. Those declining to join MACs, yet met entrance criteria, were informed that they would continue to be seen as usual through spaced clinic appointments. The MACs were conducted on Wednesday, Thursday and Saturday afternoons between 3 p.m. and 5 p.m. Timing was structured to provide maximum flexibility for patients to attend.
Patient population
All patients who were enrolled into MACs between August 2013 and 31 August 2014 were included in the study. Inclusion criteria for the MACs for hypertension and diabetes mellitus patients were as follows: ≥25 years old, >6 months on medications, having blood pressure < 150/100 and/or HBA1c <8%; for HIV patients, the inclusion criteria were as follows: ≥25 years old, >1 year on ARVs, CD4 > 200, previous viral load was undetectable and not in WHO Stage 3 or 4 active disease.
Outcomes
Outcome measures included the number and proportion of: (i) non‐communicable disease consultations where the patients’ blood pressure and/or blood sugar were below MACs threshold, (BP <150/100 mmHg, Hba1c <8.0%, respectively) whose weight was recorded and routine blood workup was requested as per the non‐communicable diseases protocol; (ii) HIV consultations where patients’ weight and blood pressure were recorded and routine blood workup was requested as per the HIV protocol; (iii) non‐communicable disease and HIV consultations where the patients were referred from MACs for clinical consultation for NCD, HIV or non‐NCD/HIV‐related problems (annual review by the clinical officer was not included as a referral back to clinic); and (iv) retention at months three, six and twelve. Lost to follow‐up was determined 3 months after a patient failed to attend a MAC session, pick up their medication and was not reported in any of the following outcomes: referred to regular clinic, transferred out or died.
Data collection and analysis
Patients’ demographic and baseline clinical characteristics were collected from the MACs register. Double data entry and validation was performed using EpiData Entry software (version 3.1, EpiData Association, Odense, Denmark). HIV variables were extracted from a FUCHIA database (version 1.7.1 Epicentre, Paris, France) and were merged with those from an EpiData database, which served as the non‐communicable diseases database. File reviews were performed for patients whose variables were missing on the electronic databases. Descriptive analysis was performed using EpiData Analysis software (version 2.2.2.182, EpiData Association, Odense, Denmark).
Ethics
Ethics approval was received from Kenya AMREF Ethics and Scientific Review Committee. The study met the Médecins Sans Frontières (MSF) Ethics Review Board (Geneva, Switzerland) approved criteria for studies of routinely collected data and was also approved by the Ethics Advisory Group of the International Union Against Tuberculosis and Lung Disease, Paris, France.
Results
A total of 1432 patients (64% female) were enrolled in 47 MACs with 109 sessions conducted between August 2013 and August 2014. Table 1 shows the demographic characteristics and clinical status of the patients at enrolment. The HIV population was younger and had been on treatment longer than the hypertension/diabetes mellitus cohort. All patients met the admission criteria.
Table 1.
Variables | HIV positive n (%) | Non‐HIV n (%) | Total n (%) |
---|---|---|---|
Total | 1020 | 412 | 1432 |
Sex | |||
Male | 405 (40) | 108 (26) | 513 (36) |
Female | 615 (60) | 304 (74) | 919 (64) |
Age (years) | |||
25–45 | 745 (73) | 168 (41) | 913 (64) |
>45–75 | 265 (26) | 243 (59) | 508 (35) |
Not recorded | 10 (1) | 1 (0) | 11 (1) |
Duration on treatment at time of enrolment (months) | |||
>6 months < 12 months | 2 (<1) | 8 (2) | 10 (0.7) |
>12 months‐24 months | 1 (<1) | 54 (13) | 55 (4) |
>24 months | 1009 (99) | 346 (84) | 1355 (95) |
Not recorded | 8 (0.8) | 4 (1) | 12 (0.8) |
Hypertensive | 12 (1) | 352 (85) | 364 (25) |
Diabetic | 0 (0) | 60 (15) | 60 (4) |
Median systolic pressure (IQR) | 122 (114–135) | 137 (125–150) | 127 (117–141) |
Median diastolic pressure (IQR) | 73 (67–80) | 80 (74–88) | 76 (69–84) |
Median HBA1c (IQR) | n/a | 8 (8.0–8.0) | |
CD4 for HIV | |||
≤200 mm3 | 47 (5) | n/a | n/a |
>201 mm3 | 969 (95) | n/a | n/a |
Viral load | |||
≤ 450 copies/ml | 999 (98) | n/a | n/a |
> 451 < 1000 copies/ml | 20 (2) | n/a | n/a |
n/a, not applicable.
Table 2 shows adherence to protocols in the MACs (appropriateness of the MACs nurse in taking weight, blood pressure and ordering routine blood tests for each patient based on the treatment guidelines). From a total of 2208 consultations, for both HIV and HT/DM patients, adherence appears to be high with blood pressure checked in 99%, weight checked in 98% and blood tests ordered correctly in 98–99% of patients.
Table 2.
Variables | HIV N = 1482 consultations | Non‐HIV N = 726 Consultations |
---|---|---|
Protocol Followed (%) | Protocol Followed (%) | |
Blood pressure checkeda | 1460 (99) | 718 (99) |
HbA1c or fasting glucose ordered (n = 59)a, b | n/a | 58 (98) |
Weight checked | 1452 (98) | 714 (98) |
Total cholesterol ordered (n = 231)a | n/a | 228 (99) |
Creatinine ordered (n = 211)a | n/a | 209 (99) |
CD4 ordered (n = 300)a | 294 (98) | n/a |
Viral load ordered (300)a | 296 (99) | n/a |
n/a: not applicable.
N varies depending on the number of patients eligible at time of data closure.
Fasting glucose was performed as an alternative to HbA1c at a time when the HbA1c machine was broken down.
Selected outcome indicators are shown in Table 3. Of 2208 consultations, 43 (2%) were referred back to the regular clinic. The reasons for referral were as follows: diabetes/hypertension management related in 28% (12), HIV management related in 14% (6), non‐HIV or non‐diabetes/hypertension related in 30% (13) and not specified 28% (12). The overall loss to follow‐up (LTFU) was 3.5% (30). LTFU occurred only between the 1st and 2nd MAC attendees. There were no known mortalities of MAC patients during the study period.
Table 3.
1st MAC | 2nd MAC | 3rd MAC | |||||||
---|---|---|---|---|---|---|---|---|---|
Total | HIV | Non‐HIV | Total | HIV | Non‐HIV | Total | HIV | Non‐HIV | |
Attended Macs (n) | 1432 | 1020 | 412 | 596 | 361 | 235 | 166 | 94 | 72 |
LTFU (%) | – | – | – | 15 (3) | 15 (4) | 0 (0) | 0 (0) | 0 (0) | 0 |
Referred to regular clinic (%) | 17 (1) | 11 (1) | 6 (1) | 5 (<1) | 2 (<1) | 3 (1) | 2 (1) | 1 (1) | 1 |
Transferred out (%) | 2 (<1) | 1 (<1) | 1 (<1) | 0 (0) | 0 (0) | 0 (0) | 0 (0) | 0 (0) | 0 |
Died (%) | 0 (0) | 0 (0) | 0 (0) | 0 (0) | 0 (0) | 0 (0) | 0 (0) | 0 (0) | 0 |
Discussion
This is the first documented study employing a group treatment model for patients with multiple chronic diseases, including HIV. There was a high degree (99%) of compliance with protocols and a small percentage (3.5%) of loss to follow‐up. There were minimal referrals (2%) back to the regular clinic for cases needing clinical officer review. However, there was some amount of selection bias within this group of patients as they represent a subcohort that was already likely highly compliant because of the study inclusion criteria.
A randomised control group was considered before study implementation, but it was felt only equitable to offer this more flexible care model to all qualifying patients because of the immediate benefits expected. Time saved and increased appointment flexibility in an informal settlement context potentially translate into increased employment opportunities and less poverty. This was reflected in the fact that patients were independently requesting a referral to join the MACs. To limit this, option of increased flexibility did not appear ethical.
Medication Adherence Clubs coped with 2208 consultations that would have been included in the regular clinic during the first year of implementation. With further scale‐up, a greater number of single provider clinic visits can be offloaded. Although specific time measurements were not recorded, the MAC group visits typically lasted less than 2 hours, which likely significantly reduced the amount of patient time during these visits.
These findings reflect stringent eligibility criteria for stable patients in MACs and suitable protocols for monitoring them. The study supports the development of MACs as an efficacious method of reducing clinicians’ workload, caring for multiple different types of stable chronic disease patients simultaneously and increasing the flexibility of care delivery for patients. It also demonstrates a low loss to follow‐up (3.5%), likely reflecting patient satisfaction, a key element in care of chronic conditions. Offering free care and medications may have been another strong incentive for patients to remain in care.
Strengths of the study were a relatively large sample size (1432), and representative of patients enrolled into MACs. Due to good management, data loss was minimal. The study was carried out during routine project operations therefore reflecting true programmatic conditions. We reported the results according to STROBE Guidelines 3.
There are limitations. The study was conducted within the first year of MACs implementation, an interval that was too short to evaluate other outcome indicators over time. However, gathering this information early in the programme provides reassurance that this model is working well. In addition, it was not possible to ascertain the amount of selection bias among the results because of the lack of a randomised control group.
Only one other study in sub‐Sahara Africa (SSA) has described a similar model, but it was limited to a single chronic disease (HIV) and included fewer (500) patients 8. This study's findings are in line with the positive results from the other study, reinforcing the soundness of the concept. Both studies showed programme similarities including urban environment, informal settlements, Clinical or Medical officer's review occurred once yearly and demonstrated improved early outcomes.
To promote further adoption and replication, the study results were shared with the Kenyan Ministry of Health and other healthcare stakeholders to enable sustainable access for chronic care treatment in resource‐constrained settings.
In conclusion, this study demonstrates the feasibility and early efficacy of Medication Adherence Clubs as a novel group treatment model to care for stable patients with mixed chronic diseases in an urban, resource‐constrained, informal settlement. It supports reducing the burden of regular clinical follow‐up among stable patients and improves the flexibility of care delivery. Further assessment on the long‐term outcomes of this model should be considered to increase confidence of deploying it in similar contexts.
Acknowledgements
We recognise the daily work of Kibera project staff, as they continue serving patients while adapting to new models of care trying to answer to the needs of the beneficiaries in a rapidly dynamic urban informal settlement of the capital Nairobi. This research was conducted through the Structured Operational Research and Training Initiative (SORT IT), a global partnership led by the Special Programme for Research and Training in Tropical Diseases at the World Health Organization (WHO/TDR). The model is based on a course developed jointly by the International Union Against Tuberculosis and Lung Disease (The Union) and Médecins sans Frontières. The specific SORT IT Programme which resulted in this publication was jointly developed and implemented by the following: the Operational Research Unit (LUXOR), Médecins Sans Frontières, Brussels Operational Center, Luxembourg; the Centre for Operational Research, The Union, Paris, France; the Centre for International health, University of Bergen, Norway; the institute of Tropical Medicine, Antwerp, Belgium; and The University of Nairobi, Kenya and the University of Chester, United Kingdom. The Programme was funded by The Union, MSF, the Department for International Development (DFID) and WHO. The funders had no role in study design, data collection and analysis, decision to publish or preparation of the manuscript.
References
- 1. MSF Belgium Kibera (MSF internal report, July 2009). Untangling the Web 2009.
- 2. Ayah R, Joshi M, Wanjiru R et al A population‐based survey of prevalence of diabetes and correlates in an urban slum community in Nairobi, Kenya. BMC public health 2013: 13: 371. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3. Oti SO, van de Vijver SJM, Agyemang C et al The magnitude of diabetes and its association with obesity in the slums of Nairobi, Kenya: results from a cross‐sectional survey. Trop Med Int Health 2013: 18: 1520–1530. [DOI] [PubMed] [Google Scholar]
- 4. van de Vijver SJM, Oti SO, Agyemangc C et al Prevalence, awareness, treatment and control of hypertension among slum dwellers in Nairobi, Kenya. J Hypertens 2013: 31: 1018–1024. [DOI] [PubMed] [Google Scholar]
- 5. Dalal W, Feikin DR, Amolloh M et al Home‐based HIV testing and counseling in rural and urban Kenyan Communities. J Acquir Immune Defic Syndr 2013: 62: e47–e54. [DOI] [PubMed] [Google Scholar]
- 6. Kenya National AIDS Control council . Kenya AIDS indicator survey 2012; www.nacc.or.ke/attachments/article/403/KAIS_II_2014_Final_Report.pdf
- 7. Sobry A, Kizito W, Van den Bergh R et al Management of hypertension and diabetes mellitus in a primary health care Programme, within a slum setting, Nairobi, Kenya, 2013. www.msf.lu/.../MSF_OR_Day_2013_Booklet_0.
- 8. Wilkinson LS. ART adherence clubs: long term retention strategy for clinically stable patients receiving antiretroviral therapy. South. Afr. J. HIV Med. 2013: 14: 48–50. [Google Scholar]
- 9. Luque‐Fernandez MA, Van Cutsem G, Goemaere E et al Effectiveness of patient adherence groups as a model of care for stable patients on antiretroviral therapy in Khayelitsha, Cape Town, South Africa. PLoS ONE 2013: 8: 1–8. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10. Médecins Sans Frontières ART adherence club report and tool kit 2012; http://www.msf.org.za/msf-publications/how-to-keep-art-patients-long-term-care-art‐ adherence‐club‐report‐and‐toolkit‐0
- 11. WHO . Global update on HIV treatment June 2013: results, impact and opportunities 2013; http://www.who.int/hiv/pub/progressreports/update2013/en/index.html
- 12. Kenya National Bureau of Statistics . Kenya population and housing census 24th/25th August 2009 2009; https://international.ipums.org/.../enum_instruct_ke2009a.pdf
- 13. UNAIDS report . Chronic care of HIV and non‐communicable diseases. How to leverage the HIV experience 2011; www.unaids.org/.../20110…
- 14. NCD Alliance . First Kenya National Forum on NCDs 2011; http://www.ncdalliance.org/node/3499.
- 15. MSF Belgium Kibera . Annual report 2013.
- 16. MSF Belgium Kibera . Patient satisfaction survey 2012.
- 17. von Elm E, Altman DG, Egger M et al Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement: guidelines for Reporting Observational Studies. PLoS Med 2007: , 10.1371. http://www.plosmedicine.org/.../info%3Adoi%2F10.1371%2Fj.4:1624-1626. 4: 1624–1626. [DOI] [PMC free article] [PubMed] [Google Scholar]