An evaluation of timeliness An evaluation of timeliness and turnaround time in and turnaround time in early infant diagnosis at early infant diagnosis at Migori District Hospital, Migori District Hospital,

Nyanza, KenyaNyanza, Kenya  

Kadima, J.1,2, Gikonyo, L.1,2 Dillabaugh, L.2,3, Owuor,K.1,2, Cohen, CR.2,3, Bukusi, EA.1,2

Kevin Owuor Statistician

UON Collaborative Meeting24th January 2013

1. Kenya Medical Research Institute (KEMRI), Nairobi, Kenya2.     Family AIDS Care and Education Services, Kisumu, Kenya3.     Departments of Pediatrics, Medicine, and Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, USA

Program BackgroundProgram Background

Family AIDS Care and Education Services (FACES)

• Family-focused program• Collaboration between Kenya Medical Research

Institute (KEMRI) and University of California, San Francisco (UCSF)

• Operational since September 2004 in Nyanza and Nairobi

FACES program areas • Provider Initiated Testing and Counseling (PITC)• Prevention of Mother to Child Transmission

(PMTCT)• HIV Care and Treatment• Voluntary Male Medical Circumcision (VMMC)

BackgroundBackground

An estimated 54,000 HIV-exposed infants are born annually in Nyanza Province

Timely early infant diagnosis (EID) is critical

Access to EID (Early Infant Diagnosis) is currently available within the region

However, delayed testing and prolonged turnaround time remain serious challenges

Infant brought for PCR Infant brought for PCR test test

To enhance EID and reduce turnaround time using a simple locally appropriate and sustainable intervention.

The intervention comprised of 1. Staff training on EID2. Establishment & enforcement of

maximum sample waiting times3. Intensified mentorship of staff4. Health talks for mothers 5. Introduction of PCR sample tracking

log

ObjectiveObjective

MethodsMethods• Retrospective cohort study

• Pre-post Intervention • Migori District Hospital

• All HIV-exposed infants who underwent PCR testing during the following timeframes were compared:

• Pre-intervention: Jul 1st 2010 to Dec 31st 2010

• Post-intervention: Jul 1st 2011 to Dec 31st 2011

• Sample size: 296 PCR tests• Pre-intervention: 155• Post-intervention: 141

Data collected from infant charts, registers, and sample tracking logs

Analysis variables extracted:

NB: All the ages and times are in days

Methods: Data CollectionMethods: Data Collection

GenderPCR resultAge at 1st PCR (Days)Enrollment age (Days)Turn-around time at facility (Days)

Enrollment to PCR (Days)Facility delay (Days)Turn-around time at main lab(Days)Main lab delay (Days)Notification delay (Days)

Infant enrollment (HEI)

PCR test at main Facility

Sample Receipt at MDH main lab

Sample Dispatch to CDC lab

Results to MDH main lab

Results to main facility

Timeliness was defined as 1st DNA PCR test done by 6 weeks of age for infants enrolled into care at the testing department (MCH and PSC). Turnaround time at the Facility was calculated as the time difference between the date of PCR test and result received at the testing point (<=23 days [timely] or more than 23 days[untimely]).

Parent Notification

PCR FlowPCR Flow

Methods: Analysis Methods: Analysis

Bivariable analysis done using T test and wilcoxon ranksum test

Univariable and Multivariable Cox proportional hazards regression used to explore the association between Pre vs. Post Intervention period and time taken in entire PCR flow

The Survival model used was the Conditional Risk Set model

Variables

Pre-Interventio

n Post-

Intervention P value

(n=155) (n=141)

Enrollment Age(Days) Mean (SD) 49.0 (13.3) 36.0 (17.1) <0.001*

Age (Days) at 1st PCR Mean (SD) 48.8 (13.2) 43.0 (10.8) <0.001*

TAT Facility (Days) Mean (SD) 33.3 (15.2) 19.1 (5.8) <0.001*

Facility Delay (Days) Median (IQR) 2 (1-5) 1 (1-2) <0.001*

TAT Main lab (Days) Median (IQR) 21 (26-32) 11 (13-17) <0.001*

Notification Delay (Days) Median (IQR) 14 (6-33) 10 (0-22) 0.010*

Results: Bivariable Results: Bivariable AnalysisAnalysis

* Statistically significant (p<0.05)

Results: Survival AnalysisResults: Survival Analysis

* Statistically significant (p<0.05)

Variable Crude

HR (95% CI)Adjusted HR (95% CI)

Period [ Ref: Pre-Intervention]  

Post-Intervention 2.41*(2.10 -

2.80) 1.5*(1.32 - 1.71)

TAT Facility [Ref: >23days]

<= 23days 2.45*(2.12 - 2.82) 1.89*

(1.67 - 2.14)

Log Rank Test : P Value <0.001

0.00

0.25

0.50

0.75

1.00

0 20 40 60 80 100Time (Days)

Pre Intervention Post Intervention

K.Meier Estimates showing Time in PCR flow by Period (Pre vs. Post)

ConclusionConclusion

• Results demonstrate that simple program interventions can result in earlier testing of HIV exposed infants and reduced turnaround time of PCR results.

Thank You