Paul Wekesa1, Margaret Ndisha2 , Boniface Makone2, Kevin Kamenwa1, Kevin Owuor1 Immaculate Mutisya2
- Centre for Health Solutions – Kenya
- Division of Global HIV&TB (DGHT), Center for Global Health, U.S. Centers for Disease Control and Prevention (CDC), Kisumu, Kenya
Background
Video directly observed therapy (vDOT) has been used as an acceptable, cost-effective, client-centered intervention for tuberculosis management. vDOT targeting children and adolescents not achieving viral suppression (VS) [<1000 copies/ml] was piloted in 128 sites in Kenya. We evaluated utilization and re-suppression rates of clients enrolled in vDOT.
Methods
A retrospective review of data from 223 (out of 470) virally unsuppressed clients aged between 0-19 years on antiretroviral therapy (ART) using the NimeCONFIRM vDOT application for at least 12 weeks between February 2021 and October 2022 at 73 facilities were conducted. Clients stopped using the application upon achieving VS. VS was assessed after at least 12 weeks of follow-up through self-care (user) or Healthcare worker (HCW)-assisted recording and upload of vDOT. Using a multivariable Fine‐Gray sub distribution hazard (SH) model we assessed demographic and clinical determinants of VS presenting adjusted sub distribution hazard ratios (aSHR) and 95% confidence interval (CI). Participants were censored on loss to follow-up, death, and transfers .
Results
Most users were aged 10-14 years (84 [37.7%]) and 15-19 years (79 [35.4%]) . Only 19 (8.5%) were on selfcare vDOT. Median time on follow up was 19.36 weeks (interquartile range [IQR]: 16.50 – 23.07), median number of videos uploaded were 126 (IQR: 96 -197), and with 75% (IQR: 60% – 85%) vDOT adherence.
About half, 108 (48.4%),%) were active, 39 (17.5%) had achieved VS, and 76 (34.1 %) discontinued. Cumulative incidence of VS was 22.1%. Results show higher incidence of VS among children aged 5-9 years compared to 0-4 years, aSHR = 3.12 (95% CI: 1.03 – 9.39) and those on self-care compared to healthcare worker led option, aSHR = 2.51 (95% CI: 1.95 – 3.24). Similarly, there was higher incidence of VS for those with guardians and siblings as caregivers compared to grandparents; aSHR = 1.28 (95% CI: 1.11- 1.48), and aSHR = 2. 83 (95% CI: 1.83 – 4.37), respectively.
Conclusion:
Achieving VS using vDOT was significantly associated with age, self-care option, and type of caregiver. Findings suggest vDOT as an additional tool to support unsuppressed children and adolescents to achieve more equitable health outcomes.
Table 1. Gray-Fine competing risks model for viral suppression during the follow up period while using the NIMECONFIRM application (At least 12 weeks)
| Outcome: Viral Suppression while using app * | Subdistribution Hazard Ratio ^ | Adjusted Sub-distribution Hazard Ratio ^ | ||
| User Characteristics | SHR (95% CI) | P value | aSHR (95% CI) | P value |
| Sex | ||||
| Girls | Reference | Reference | ||
| Boys | 1.29 (0.83 – 2.00) | 0.265 | 1.56 (0.78 – 3.11) | 0.209 |
| Age Category | ||||
| 0-4yrs | Reference | Reference | ||
| 5-9yrs | 3.40 (0.99 – 11.71) | 0.052 | 3.12 (1.03 – 9.39) | 0.043 |
| 10-14yrs | 2.05 (0.50 – 8.49) | 0.32 | 1.78 (0.58 – 5.41) | 0.312 |
| 15-19yrs | 1.46 (0.32 – 6.62) | 0.625 | 1.06 (0.26 – 4.31) | 0.937 |
| Caregiver | ||||
| Grandfather | Reference | Reference | ||
| Guardian | 1.24 (1.00 – 1.54) | 0.054 | 1.28 (1.11 – 1.48) | 0.001 |
| Parent | 0.94 (0.53 – 1.68) | 0.841 | 1.03 (0.60 – 1.77) | 0.927 |
| Relative | 1.25 (0.72 – 2.17) | 0.431 | 1.69 (0.67 – 4.23) | 0.264 |
| Siblings | 1.96 (1.72 – 2.24) | <0.001 | 2.83 (1.83 – 4.37) | <0.001 |
| Dosage Frequency | ||||
| Twice Daily | Reference | Reference | ||
| Once Daily | 1.68 (1.22 – 2.30) | 0.001 | 1.42 (0.53 – 3.86) | 0.488 |
| Core regimen | ||||
| ABC Based | Reference | Reference | ||
| AZT Based | 2.08 (1.42 – 3.04) | <0.001 | 1.62 (0.87 – 3.01) | 0.128 |
| TDF Based | 1.88 (1.09 – 3.23) | 0.022 | 1.83 (0.54 – 6.16) | 0.329 |
| Care Type | ||||
| Healthcare Worker Led | Reference | Reference | ||
| Self-Care | 2.051.33 – 3.15) | 0.001 | 2.51 (1.95 – 3.24) | <0.001 |
* Any discontinuation was a competing event
^ Project level clustering accounted for
Figure 1. Cumulative Incidence of Viral Suppression by Age Category after 12 weeks of using application
Figure .2. Cumulative Incidence of Viral Suppression by Caregiver type after 12 of weeks using application
