The findings from KAIS 2012 provide population-level data on access to and quality of HIV care services among HIV-infected persons. Our data show evidence of success in linking HIV-infected persons who were aware of their infection into HIV care, in retaining persons in care, in the use of the recommended components of care including cotrimoxazole and ART, and in achieving viral suppression among those on ART.
Importantly, we found that 96% of HIV-infected persons currently in care were taking cotrimoxazole, highlighting progress since KAIS 2007, when 89% of HIV-infected persons who were aware of their HIV infection were taking cotrimoxazole.12 Revision of policy guidelines for care and treatment, decentralization of care and treatment services, capacity building of the health workforce, and improved procurement of supplies have contributed to improvements in the proportion of HIV-infected persons receiving care.13 Access to cotrimoxazole is used routinely by the Government of Kenya as a programmatic indicator of engagement in care; our results support its continued utility in approximating access to HIV care among HIV-infected persons. Although differences in study designs limit direct comparisons, the proportion of HIV diagnosed persons reporting current use of care in Kenya is comparable to results from other studies in the United States.14,15
Despite this progress, we also identified areas where improvement is needed. In particular, we found that persons who were in care but had not yet initiated ART were less likely to have a recent clinic visit, less likely to be receiving cotrimoxazole, and less likely to have a CD4+ T-cell count measurement than persons who were on ART. Moreover, nearly one-quarter of these individuals were eligible for ART based on the current immunologic criterion for ART initiation in Kenya. Studies from other resource-constrained settings have also found suboptimal care outcomes in the pre-ART population, including high rates of loss to follow-up, death, and failure to return to the clinic for CD4+ T-cell count testing.16–18 To a large extent, a patient's CD4+ T-cell count determines eligibility for ART initiation. Therefore, failure to meet timely initiation of ART based on immunologic criterion can result in increased morbidity and mortality. Although the reasons for these findings have not been fully investigated, it is possible that shortages in reagents for CD4+ T-cell count testing and cotrimoxazole supplies could have impacted access to these services for pre-ART populations. Under such circumstances, health care workers prioritize care for those in greatest need, such as persons receiving ART. Such differences among persons in care must be explored further, and if adherence to clinical care guidelines is found to be suboptimal, retraining of health care staff should be prioritized. Given our findings of differential care among persons based on receipt of ART, raising the immunologic threshold for ART initiation, as recommended by the World Health Organization,19 to CD4 ≤500 cells per microliter could potentially improve retention in care and access to recommended services, resulting in better clinical outcomes.
Three-quarters of HIV-infected persons who were currently in care and on ART had achieved viral suppression. These findings are consistent with other studies that have reported that 78%–93% of persons on ART were virologically suppressed.14,15 It is possible that this is an underestimate of true population levels of viral suppression on ART. Because we did not determine the duration of ART use, some subjects may have recently started therapy and not yet reached viral suppression. Alternatively, because viral load monitoring is not currently a routine part of care, unsuppressed persons may reflect true treatment failures or poor adherence to ART.20,21 Our finding of viral suppression in 30% of persons who were not currently using ART is surprising because elite controllers of HIV infection are considered to be rare.22–24 Although a study of undiagnosed men in San Francisco had a similar finding, other factors must be considered.25 Persons receiving ART may have been misclassified, or laboratory error in the viral load results may have contributed to this finding. Furthermore, persons who reported that they were not currently receiving ART may have recently or temporarily discontinued treatment because of difficulty returning to the pharmacy for refills or insufficient drug supplies. Continued exploration of this finding is warranted, including a detailed assessment of respondents' understanding of the question and laboratory analysis of blood samples for the presence of antiretroviral drugs in untreated and suppressed persons.
There are limitations to consider when interpreting the findings from our study. First, we relied on self-reported data that may have underestimated the proportion of persons who were aware of their HIV infection and may have overestimated the use of care. Recall of events in the distant past may have resulted in inaccurate responses. Potential bias could have resulted from the substantial number of blood specimens that were hemolyzed and unable to be used for CD4+ T-cell measurements. However, no significant differences in demographic characteristics were observed between HIV-infected persons with and without CD4+ T-cell count data, leading us to believe that this limitation did not bias our findings. Finally, although the survey excluded the North Eastern region, this region has a HIV prevalence of <1%, and its exclusion is not likely to have impacted our findings.12
We believe that these limitations are offset by the strength of the nationally representative sample and that our estimates provide essential information on use of HIV-related care services among persons with known HIV infection. Although progress has been made in diagnosing and treating HIV-infected persons in Kenya, our study identified important priorities for the future including provision of essential medical services to persons before initiating ART. Our study also confirms that there is a loss of persons along the path from diagnosis to viral suppression, resulting in a sizable proportion of diagnosed persons in need of ART who are not receiving it and capable of transmitting infection. Continued exploration of factors that undermine providing care to all persons diagnosed with HIV infection and corrective interventions are needed.
The authors thank the fieldworkers and supervisors for their work during KAIS data collection and the individuals who participated in this national survey. The authors thank Joy Mirjahangir, Veronica Lee, George Rutherford, and Kevin DeCock for reviewing and providing suggestions on the manuscript. They also thank the KAIS Study Group for their contribution to the design of the survey and collection of the data set: Willis Akhwale, Sehin Birhanu, John Bore, Angela Broad, Robert Buluma, Thomas Gachuki, Jennifer Galbraith, Anthony Gichangi, Beth Gikonyo, Margaret Gitau, Joshua Gitonga, Mike Grasso, Malayah Harper, Andrew Imbwaga, Muthoni Junghae, Mutua Kakinyi, Samuel Mwangi Kamiru, Nicholas Owenje Kandege, Lucy Kanyara, Yasuyo Kawamura, Timothy Kellogg, George Kichamu, Andrea Kim, Lucy Kimondo, Davies Kimanga, Elija Kinyanjui, Stephen Kipkerich, Danson Kimutai Koske, Boniface O. K'Oyugi, Veronica Lee, Serenita Lewis, William Maina, Ernest Makokha, Agneta Mbithi, Joy Mirjahangir, Ibrahim Mohamed, Rex Mpazanje, Silas Mulwa, Nicolas Muraguri, Patrick Murithi, Lilly Muthoni, James Muttunga, Jane Mwangi, Mary Mwangi, Sophie Mwanyumba, Francis Ndichu, Anne Ng'ang'a, James Ng'ang'a, John Gitahi Ng'ang'a, Lucy Ng'ang'a, Carol Ngare, Bernadette Ng'eno, Inviolata Njeri, David Njogu, Bernard Obasi, Macdonald Obudho, Edwin Ochieng, Linus Odawo, Jacob Odhiambo, Caleb Ogada, Samuel Ogola, David Ojakaa, James Kwach Ojwang, George Okumu, Patricia Oluoch, Tom Oluoch, Kenneth Ochieng Omondi, Osborn Otieno, Yakubu Owolabi, Bharat Parekh, George Rutherford, Sandra Schwarcz, Shanaaz Sharrif, Victor Ssempijja, Lydia Tabuke, Yuko Takanaka, Mamo Umuro, Brian Eugene Wakhutu, Celia Wandera, John Wanyungu, Wanjiru Waruiru, Anthony Waruru, Paul Waweru, Larry Westerman, and Kelly Winter.
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Keywords:© 2014 by Lippincott Williams & Wilkins
HIV; viral suppression; antiretroviral therapy; cotrimoxazole; Kenya