Case study: Using AfyaSTAT, a Community Health Toolkit (CHT)-powered app to enable HIV testing within facility and community settings in Kenya

This case study was collaboratively authored by the above organizations. Individual authors include: Benard Ajwang, Palladium Kenya; Pascal Mwele, Palladium Kenya; Rhoda Obonyo, CHS Kenya; Jacquin Kataka, CHS Kenya; Antony Khaemba, Medic; Simon Mbae, Medic.

Overview of partnership

In March 2020, when COVID-19 had not fully established itself in Kenya, an opportunity emerged for Medic and Palladium Kenya to not only co-develop an integrated COVID-19 surveillance system with the Ministry of Health (MoH) and other stakeholders, but also to exchange knowledge between the two organizations on respective technologies. Being open-source and technology-centered organizations, the partnership was premised on the principles of digital development with an aim of mutually advancing and extending capabilities of the two technologies – OpenMRS (released under the name KenyaEMR) and the Community Health Toolkit (CHT) – for a seamless data exchange and closed-loop client journey from the community to the health facility. 

Implemented by Palladium Kenya, the Kenya Health Management Information System (KeHMIS) project is a PEPFAR-funded initiative with the goal of supporting the MoH, county health management teams, and service delivery partners to develop and maintain health information systems (HIS) innovations in Kenya. Palladium Kenya partnered with MoH and other stakeholders to design and develop a CHT-based mobile app for the project – named AfyaSTAT – that centers on HIV testing and screening (HTS) as an entry point to HIV care and treatment. Interoperable with KenyaEMR and supportive of both facility-based HTS workflows and outreach services to key populations, AfyaSTAT’s offline and online modes enable delivery of integrated HIV preventive and treatment services at the community-level.

About Palladium Kenya

Palladium Kenya implements the Kenya HMIS project, which is a PEPFAR-funded project with the goal of supporting the Ministry of Health, County Health Management Teams, and Service Delivery Partners in developing and maintaining Health Information Systems innovations in the Republic of Kenya. The project develops Electronic Medical Records systems (KenyaEMR), mHealth applications (including AfyaSTAT), a data repository (National Data Warehouse) and systems integration solution (Interoperability Layer (IL)). The key mandate is to develop and maintain the solutions, provide technical support to stakeholders, capacity build stakeholders, and develop information products.

About Centre for Health Solutions Kenya (Siaya Mechanism)

Centre for Health Solutions (CHS) Kenya is a local not for profit organization that utilizes local expertise and strategic partnerships to implement evidence-informed solutions and interventions to existing and emerging public health needs. CHS supports the implementation of Electronic Medical Records (EMR) systems in 119 health facilities and electronic HIV Testing Services (eHTS) in 42 health facilities to support client management and improve data completeness, accuracy and timely reporting in Siaya County. 

CHS Kenya has been at the forefront of adopting new Health Information Systems (HIS) tools and has actively supported testing, deployment, implementation and resource allocation of all the EMR products.

About Medic

Medic builds and deploys open-source digital tools that help health workers deliver just, quality care to their neighbors and community. Medic serves as technical steward and core contributor of the CHT, a collection of free and open-source technologies; open-access design, technical, and implementer resources; and a community of practice. As stewards, Medic’s focus is to build and support the CHT as a global public good; partner with Ministries of Health, NGOs, and technical organizations to design, deploy, and scale digital health apps powered by the CHT; and advance R&D for precision global health. 

How AfyaSTAT is uniquely suited in the HIV care and treatment cascade

An HIV test and screening (HTS) is the entry point to HIV care and treatment programs. A positive test outcome means that the client needs to be linked to HIV care and treatment while a negative test outcome forms the basis for enrollment into HIV prevention through Pre-Exposure Prophylaxis (PrEP) and Post-Exposure Prophylaxis (PEP) services as required.

An appropriate digital health solution must take into account the HTS workflow at the facility and support outreach services for key populations (KP), PrEP, PEP and HIV Partner Notification Services (PNS) testing in the communities. AfyaSTAT is founded on this. Its offline and online modes support delivery of integrated HIV preventive and treatment services in the community and facility settings and currently supports both HTS services and KP program areas.

The AfyaSTAT app is interoperable with KenyaEMR, and the two systems have been configured to manage HIV testing services, referrals, contact listing, and index testing. Service Providers using the app are able to register HTS clients, fill HTS forms, do contact listing, and fill the linkage and referral forms. Once data is synced on AfyaSTAT, the information on HTS clients, contacts listed, and referrals are automatically pushed from AfyaSTAT to KenyaEMR, and the information can be accessed on KenyaEMR. The KenyaEMR system shares HTS information with AfyaSTAT, including positive cases tested in KenyaEMR that are not linked to care. Providers can trace the cases through AfyaSTAT and link patients to care, as well as contact HTS clients listed on KenyaEMR who are not tested. Service providers are also able to view the cumulative number of clients tested in a month, and this information is available on the in-app analytics tab. The KenyaEMR_AfyaSTAT integration makes it easy to uniquely track individual clients across the HIV care continuum – from testing to enrollment to treatment. This factor makes the solution suitable to meet case reporting and HIV surveillance needs as prioritized by HIV programs in Kenya.

AfyaSTAT’s minimum viable product was released in October 2020. In June 2021, AfyaSTAT was officially launched for public deployment in Kenya. A roadmap for transition from previous electronic HTS tools to AfyaSTAT was adopted by 30 HIV and TB Service Delivery Implementing Partners (SDIP) during the launch event.

AfyaSTAT Pilot and Adoption in Siaya County

In March 2021, the AfyaSTAT app was piloted in two facilities in Siaya County supported by CHS Kenya at Kogelo Dispensary, and Bar Olengo Dispensary. The AfyaSTAT pilot provided an opportunity to test and enhance both the application and its deployment approach. 

Map of Siaya sub-counties where AfyaSTAT is implemented

Following the successful pilot, CHS Kenya adopted and scaled AfyaSTAT to 40 additional facilities with approximately 120 Service Providers trained on AfyaSTAT. These 42 facilities have fully transitioned from the legacy system, mUzima. This adoption has led to 100% coverage of CHS Kenya (Siaya Mechanism) eHTS sites. 

The Kenya HMIS project continues to work with the Regional Strategic Information (SI) Officers. The SI Officers support user training, provide technical and data validation support. This support has been the engine driving the successful implementation

Since the Service Providers at Kogelo Dispensary started using the AfyaSTAT app, the following has been observed:

  • 100% daily linkage of all clients has been achieved at the facility, per Antony Ambogo (a Health Records Information Officer at Kogelo Dispensary). 
  • Ability to detect previously-identified Known Positives who come to the facility to test by flagging their records through the error queue. For instance, the facility identified a client who had dropped out of care from the facility in 2016 when he sought testing in April 2021, per Evelyn Ayuma, HTS provider at Kogelo Dispensary.     

Compared with other data sources; paper register and National Data Warehouse, AfyaSTAT-generated data achieved good parity with the two. Consistently low deviation was observed over a six months period post introduction of AfyaStat.

AfyaSTAT mobile application user interface

Improved User Experience with AfyaSTAT

In addition to the offline functionality, HTS service providers find it faster to do a HIV test with AfyaSTAT in part due to pre-populated options and sequential availability of forms which reinforce provider observance of HTS workflow. This streamlined entry ensures capture of high quality data and enforces sequential task completions without skipping steps.

AfyaSTAT navigation presents an intuitive and familiar order of HTS forms that load quickly, fast leading to well-guided and timely HTS data update. Inclusion of system alerts, prompts, and notifications provide useful user feedback.

With AfyaSTAT, recording is done once, with client details becoming available in realtime at successive service points, making it easier to confirm and update client details at adherence or clinic service points.

For program Monitoring and Evaluation (M&E), AfyaSTAT has made it possible to know what records are defective (for example: positive clients presenting for testing). Such records are placed in the error queue unlike the experience with the previous mobile application.

HRIO Reviews AfyaSTAT Dashboard at Kogelo Dispensary

Another feature the users found fascinating is the ability to place a call to a client straight from the AfyaSTAT app when updating client tracing. 

Future desired enhancements to AfyaSTAT include access to the error queue, better handling of offline/online modes, and provision of workload summary per provider.

“We are ready to drop all HTS registers as all records are in the AfyaSTAT.”

Antony Ambogo (HRIO – Kogelo)

What’s Next

AfyaSTAT is expected to scale through CHS Kenya (Siaya Mechanism) new project phase as well as through other service delivery partners. Palladium Kenya and Medic will continue to collaborate to address AfyaSTAT-EMR technical challenges and work with end users to improve usability. To ensure AfyaSTAT remains relevant to the program, users and context, Palladium will leverage new CHT Core Framework version releases as well as contribute in roadmapping opportunities to build new capabilities. It is envisioned that additional use cases – such as electronic voluntary medical male circumcision (eVMMC) and community Antiretroviral Therapy (ART) management use cases – will also be incorporated into future app updates.

Beyond AfyaSTAT, Palladium and Medic will continue to explore opportunities to advance the partnership, jointly working towards a more connected, interoperable, human-centered health system serving communities across Kenya and advancing universal health coverage for all.

Disclaimer

The conclusions, findings, and opinions expressed by authors contributing to this article do not necessarily reflect the official position of the U.S. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors’ affiliated institutions.  Use of trade names is for identification only and does not imply endorsement by the Public Health Service or by the U.S. Department of Health and Human Services.

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