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Kurth A.E.,New York University | Cleland C.M.,New York University | Des Jarlais D.C.,Rothschild | Musyoki H.,National AIDS and STI Control Programme NASCOP | And 3 more authors.
Journal of Acquired Immune Deficiency Syndromes | Year: 2015

Objective: HIV infection in sub-Saharan Africa increasingly occurs among people who inject drugs (PWID). Kenya is one of the first to implement a national needle and syringe program. Our study undertook a baseline assessment as part of evaluating needle and syringe program in a seek, test, treat, and retain approach. Methods: Participants enrolled between May and December 2012 from 10 sites. Respondent-driven sampling was used to reach 1785 PWID for HIV-1 prevalence and viral load determination and survey data. Results: Estimated HIV prevalence, adjusted for differential network size and recruitment relationships, was 14.5% in Nairobi (95% CI: 10.8 to 18.2) and 20.5% in the Coast region (95% CI: 17.3 to 23.6). Viral load (log10 transformed) in Nairobi ranged from 1.71 to 6.12 (median: 4.41; interquartile range: 3.51-4.94) and in the Coast from 1.71 to 5.88 (median: 4.01; interquartile range: 3.44- 4.72). Using log10 viral load 2.6 as a threshold for HIV viral suppression, the percentage of HIV-infected participants with viral suppression was 4.2% in Nairobi and 4.6% in the Coast. Heroin was the most commonly injected drug in both regions, used by 93% of participants in the past month, typically injecting 2-3 times/day. Receptive needle/syringe sharing at last injection was more common in Nairobi (23%) than in the Coast (4%). Estimated incidence among new injectors was 2.5/100 person-years in Nairobi and 1.6/100 person-years in the Coast. Conclusions: The HIV epidemic is well established among PWID in both Nairobi and Coast regions. Public health scale implementation of combination HIV prevention has the potential to greatly limit the epidemic in this vulnerable and bridging population. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.


Anderson S.-J.,Imperial College London | Cherutich P.,National AIDS and STI Control Programme NASCOP | Kilonzo N.,Liverpool VCT Care and Treatment | Cremin I.,Imperial College London | And 8 more authors.
The Lancet | Year: 2014

Background Epidemiological data show substantial variation in the risk of HIV infection between communities within African countries. We hypothesised that focusing appropriate interventions on geographies and key populations at high risk of HIV infection could improve the effect of investments in the HIV response. Methods With use of Kenya as a case study, we developed a mathematical model that described the spatiotemporal evolution of the HIV epidemic and that incorporated the demographic, behavioural, and programmatic differences across subnational units. Modelled interventions (male circumcision, behaviour change communication, early antiretoviral therapy, and pre-exposure prophylaxis) could be provided to different population groups according to their risk behaviours or their location. For a given national budget, we compared the effect of a uniform intervention strategy, in which the same complement of interventions is provided across the country, with a focused strategy that tailors the set of interventions and amount of resources allocated to the local epidemiological conditions. Findings A uniformly distributed combination of HIV prevention interventions could reduce the total number of new HIV infections by 40% during a 15-year period. With no additional spending, this effect could be increased by 14% during the 15 years-almost 100 000 extra infections, and result in 33% fewer new HIV infections occurring every year by the end of the period if the focused approach is used to tailor resource allocation to reflect patterns in local epidemiology. The cumulative difference in new infections during the 15-year projection period depends on total budget and costs of interventions, and could be as great as 150 000 (a cumulative difference as great as 22%) under different assumptions about the unit costs of intervention. Interpretation The focused approach achieves greater effect than the uniform approach despite exactly the same investment. Through prioritisation of the people and locations at greatest risk of infection, and adaption of the interventions to reflect the local epidemiological context, the focused approach could substantially increase the efficiency and effectiveness of investments in HIV prevention. Funding The Bill &Melinda Gates Foundation and UNAIDS.


Boruett P.,Management science for Health | Kagai D.,National AIDS and STI Control Programme NASCOP | Njogo S.,National AIDS and STI Control Programme NASCOP | Nguhiu P.,Management science for Health | And 6 more authors.
BMC Health Services Research | Year: 2013

Background: Achieving high rates of adherence to antiretroviral therapy (ART) in resource-poor settings comprises serious, but different, challenges in both the first months of treatment and during the life-long maintenance phase. We measured the impact of a health system-oriented, facility-based intervention to improve clinic attendance and patient adherence. Methods. This was a quasi-experimental, longitudinal, controlled intervention study using interrupted time series analysis. The intervention consisted of (1) using a clinic appointment diary to track patient attendance and monitor monthly performance; (2) changing the mode of asking for self-reported adherence; (3) training staff on adherence concepts, intervention methods, and use of monitoring data; (4) conducting visits to support facility teams with the implementation.We conducted the study in 12 rural district hospitals (6 intervention, 6 control) in Kenya and randomly selected 1894 adult patients over 18 years of age in two cohorts: experienced patients on treatment for at least one year, and newly treated patients initiating ART during the study. Outcome measures were: attending the clinic on or before the date of a scheduled appointment, attending within 3 days of a scheduled appointment, reporting perfect adherence, and experiencing a gap in medication supply of more than 14 days. Results: Among experienced patients, the percentage attending the clinic on or before a scheduled appointment increased in both level (average total increase immediately after intervention) (+5.7%; 95% CI = 2.1, 9.3) and trend (increase per month) (+1.0% per month; 95% CI = 0.6, 1.5) following the intervention, as did the level and trend of those keeping appointments within three days (+4.2%; 95% CI = 1.6, 6.7; and +0.8% per month; 95% CI = 0.6, 1.1, respectively). The relative difference between the intervention and control groups based on the monthly difference in visit rates increased significantly in both level (+6.5; 95% CI = 1.4, 11.6) and trend (1.0% per month; 95% CI = 0.2, 1.8) following the intervention for experienced patients attending the clinic within 3 days of their scheduled appointments.The decrease in the percentage of experienced patients with a medication gap greater than 14 days approached statistical significance (-11.3%; 95% CI = -22.7, 0.1), and the change seemed to persist over 11 months after the intervention. All facility staff used appointment-keeping data to calculate adherence and discussed outcomes regularly. Conclusion: The appointment-tracking system and monthly performance monitoring was strengthened, and patient attendance was improved. Scale-up to national level may be considered. © 2013 Boruett et al.; licensee BioMed Central Ltd.

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