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Evaluation of impact of long-lasting insecticide-treated bed nets and point-of-use water filters on HIV-1 disease progression in Kenya

Walson, Judd L.a,b,c,d,f; Sangaré, Laura R.a; Singa, Benson O.f; Naulikha, Jacqueline Mulongoc,f; Piper, Benjamin K.S.c,f; Yuhas, Kristab; Onchiri, Frankline Magakie; Otieno, Phelgona A.f; Mermin, Jonathang; Zeh, Clementg; Richardson, Barbra Anna,e,h; John-Stewart, Gracea,b,c,d

doi: 10.1097/QAD.0b013e32835ecba9
Epidemiology and Social

Objectives: Among HIV-1-infected individuals in Africa, coinfection with malaria and diarrhoeal disease may be associated with more rapid HIV-1 disease progression. We sought to determine whether the use of long-lasting insecticide-treated bed nets and simple point-of-use water filters can delay HIV-1 disease progression.

Design: A prospective cohort study.

Setting: Two HIV care sites in Kenya.

Participants: HIV-1-infected adults not yet meeting criteria for antiretroviral therapy.

Interventions: One group received the standard of care, whereas the other received long-lasting insecticide-treated bed nets and water filters. Individuals were followed for up to 24 months.

Main outcome measures: The primary outcome measures were time to CD4 cell count less than 350 cells/μl and a composite endpoint of time to CD4 cell count less than 350 cells/μl and nontraumatic death. Time to disease progression was compared using Cox proportional hazards regression.

Results: Of 589 individuals included, 361 received the intervention and 228 served as controls. Median baseline CD4 cell counts were similar (P = 0.36). After controlling for baseline CD4 cell count, individuals receiving the intervention were 27% less likely to reach the endpoint of a CD4 cell count less than 350 cells/μl (hazard ratio 0.73; 95% confidence interval 0.57–0.95). CD4 cell count decline was also significantly less in the intervention group (−54 vs. −70 cells/μl per year, P = 0.03). In addition, the incidence of malaria and diarrhoea were significantly lower in the intervention group.

Conclusion: Provision of a long-lasting insecticide-treated bed net and water filter was associated with a delay in CD4 cell count decline and may be a simple, practical and cost-effective strategy to delay HIV-1 progression in many resource-limited settings.

aDepartment of Global Health

bDepartment of Medicine

cDepartment of Pediatrics

dDepartment of Epidemiology

eDepartment of Biostatistics, University of Washington, Seattle, Washington, USA

fKenya Medical Research Institute, Centre for Clinical Research, Nairobi, Kenya

gCenters for Disease Control and Prevention, Atlanta, Georgia

hFred Hutchinson Cancer Research Center, Vaccine and Infectious Disease Division, Seattle, Washington, USA.

Correspondence to Judd L. Walson, MD, MPH, Department of Global Health, University of Washington, 325 Ninth Avenue, Box 359931, Seattle, WA 98104, USA. E-mail:

Received 2 November, 2012

Revised 2 January, 2013

Accepted 9 January, 2013

© 2013 Lippincott Williams & Wilkins, Inc.