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During public health crises, people living with HIV (PLWH) may become disengaged from care. The goal of this study was to understand the impact of the COVID-19 pandemic and recent flooding disasters on HIV care delivery in western Kenya. We conducted ten individual in-depth interviews with HIV providers across four health facilities. We used an iterative and integrated inductive and deductive data analysis approach to generate four themes. First, increased structural interruptions created exacerbating strain on health facilities. Second, there was increased physical and psychosocial burnout among providers. Third, patient uptake of services along the HIV continuum decreased, particularly among vulnerable patients. Finally, existing community-based programs and teleconsultations could be adapted to provide differentiated HIV care. Community-centric care programs, with an emphasis on overcoming the social, economic, and structural barriers will be crucial to ensure optimal care and limit the impact of public health disruptions on HIV care globally.
This study was conducted within the Academic Model Providing Access to Healthcare (AMPATH) in western Kenya. AMPATH is an academic partnership between Moi University, Moi Teaching and Referral Hospital, and a consortium of academic institutions led by Indiana University.19 Since 2001, AMPATH has been a key partner of the Kenya Ministry of Health (MOH) and the National AIDS and STI Control Program to create and implement prevention and treatment programs to support HIV patients. To date, the program has provided HIV care services for approximately 110,000 + active patients living with HIV across 300 + MOH-supported clinics in western Kenya.20 AMPATH also provides primary- to tertiary-level care services at health facilities, and community-based care programs including community-based medication deliveries through community-ART groups (CAGs), community-based care delivery for non-communicable diseases and maternal and child health, and economic programs to address social determinants of health through group-based microfinance, agricultural, and income generation activities.21–26 For HIV care, established and stable HIV patients within the AMPATH program are routinely seen by HIV-trained clinicians with a 3–6 month return-to-clinic (RTC) date for follow-ups.17 The clinician-to-patient ratio is estimated to be 1:1300–1550.27 All HIV clinical visits, labs, and medications are provided at no cost to patients. Antiretroviral therapies (ART) are given for a duration of 3 months, after which a patient may come back to the health facility to receive a refill. Eligible patients are enrolled in CAGs where they receive ART delivered to them in the community every 3 months, with an in-person clinical visit at the facility every 6 months. Viral loads for virally suppressed patients are ordered and taken at the facility laboratory every 12 months. For patients who are not virally suppressed, a repeat viral load test is typically ordered after 3 months in combination with enhanced adherence counseling. All viral load testing procedures comply with recommendations from the National AIDS and STI Control Program, MOH in Kenya.28 The study was conducted at four health facilities in two counties, Busia and Trans Nzoia, within the AMPATH catchment area. Selection of the counties was based on their long-standing HIV care infrastructure through facility-based and differentiated community-based care via CAGs.21,25 Additionally, at the time of the study, the counties were sites for our clinical trial in which a community-based HIV intervention would be deployed (ClinicalTrials.gov Identifier: {“type”:”clinical-trial”,”attrs”:{“text”:”NCT04417127″,”term_id”:”NCT04417127″}}NCT04417127). Selection of the health facilities within the two counties was informed by two main factors; one was the presence/absence of flooding events (Busia County was severely affected by floods), and the other was the level of site-specific and locally imposed COVID-19 restrictions (while the government issued safety recommendations, how these recommendations were implemented may vary between and within counties based on the local administration, COVID infection severity, and available resources at each site. In Trans Nzoia county, one study site had a stricter implementation of COVID safety recommendations than the other.) Between October and December 2020, we conducted 10 telephone-based individual in-depth interviews with HIV providers to explore the impact of COVID-19 on HIV care delivery, the impact of COVID-19 on providers and patients, and mitigation strategies employed to alleviate the downstream impact on HIV treatment outcomes, including ART delivery and telemedicine. A semistructured interview guide was designed to elicit information in these specific areas from HIV providers who continued to provide care for HIV patients during the early phases of the COVID-19 pandemic and in the aftermath of the flooding. Trained researchers identified, contacted, and obtained informed consent from participants. Each interview lasted approximately one hour and was conducted on the telephone in English and/or Swahili. At the end of each interview, participants were compensated with 500 Kenyan shillings (approximately 5 US dollars) in appreciation for their time. We invited 10 HIV care providers from four different health facilities in the two specified counties. Participants were chosen because they were frontline clinicians or nurses providing care to HIV patients during the COVID-19 pandemic. All participants directly provided care for patients at the health facilities, and some played leadership roles within facilities. Selection of the providers was also based on the number of years that they had been providing HIV care and number of years on staff at AMPATH. In addition, providers holding various clinical and administrative positions were invited to ensure different types of responsibilities were captured. The number of interviews was based on our consensus that interviews would not disrupt providers’ care responsibilities while ensuring that content saturation would be reached. Verbal consent was obtained from all participants prior to commencing the interviews. Data collection was conducted by experienced researchers from the AMPATH Social-Behavioral Team. All interviews were audio-recorded. Recorded interviews were transcribed in full and then translated into English. De-identified text data were imported to NVivo (Copyright © 1999-2021 QSR International) for analysis. An iterative and integrated inductive and deductive data analysis approach was used. A codebook containing deductive codes was generated based on a priori identified areas as per the semistructured interview guide. As new information emerged, inductive codes were added to the codebook. Ideas from different interviews were pooled together, reviewed, discussed, and integrated into common themes. A team of three qualitative analysts conducted a two-stage approach to coding and text analysis. First, one analyst (HK) conducted a first-level coding exercise to identify ideas and themes related to the impact of COVID on the providers, the perceived effects on HIV patients, and their thoughts on specific mitigation strategies to deliver HIV care during COVID-19. After first-level coding, second-level coding was conducted by the other two analysts (DT and JC) who merged overlapping codes, identified, discussed, and further refined common and emerging themes. These themes are presented in the results as summary statements, with quotes provided for elaboration and illustrative purposes. This study was approved by the Moi Teaching and Referral Hospital/Moi University Institutional Research and Ethics Committee, Eldoret, Kenya, under Reference IREC/2020/120, Approval Number 0003659. Verbal consent was obtained from all participants prior to commencing the interviews. The study investigators provided verbal informed consent, instead of written informed consent, for the following reasons. First, the study period occurred between October and December 2020, before the availability of any COVID-19 vaccines and during a time when social and physical distancing was advised in Kenya. Limiting physical interactions whenever possible to avoid the unnecessary spread of COVID-19 to participants was a safety priority of our research team. All interviews and informed consent were conducted via the telephone. During the consent process, the interviewer provided a description of the study (ie, introduction, purpose, procedures, reimbursement, confidentiality, risks, and benefits) to participants. Participants were free to ask follow-up questions about the study. Finally, participants were asked to verbally state if they would be willing to take part in the interview. No identifiable information was recorded at any time during the interview.
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