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Early access to voluntary HIV counseling and testing, bed nets and water filters through an
integrated campaign in Kenya: potential impact on HIV and TB transmission
Reuben GranichHIV/AIDS Department
World Health Organization
International AIDS Conference, Vienna
July 18-23, 2010
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Outline:
• Background
• Methods
• Results
• Conclusions
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Smallpox eradication 1796 to 1977:Edward Jenner to Merca Town, Somalia
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Campaigns against Guinea Worm
Guinea worm eradication
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Campaigns against preventable blindnessPreventable blindness
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Community counseling and testing is feasible and works in a wide variety of settings
Photos courtesy of Bunnell R, Marum E, and Vestergaard Frandsen
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Late initiation of ART and mortality
Source: Egger M, CROI 2007
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Havlir, Getahun et al. 2008 JAMA 300(4):423-430
CD4 level is associated with TB incidence:earlier start may decrease TB risk
"TB death zone"
Slide adapted by Dr. Abhishek Sharma
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Coverage of ART among eligible people living with HIV
Kenya (2007 KAIS)
HIV test
57% Unaware of status, not
on ART
4% know status, not on ART
39% know status,
on ART
Among those who knew status and were eligible 92% were on ARTMohammed, CROI 2009
57%
39%
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• ~1,300,000 persons living with HIV (15-64yrs)
• Prevalence 7.1% • range (1% to 15%)
• Nyanza and Rift Valley home to >50% of HIV-infected adults (15-64 yrs)
Kenya Aids Indicator survey (KAIS) 2007
Population – 37,538,000
Kisii
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Kisii (Nyanza) campaign sites
Kisii Level 5 Hospital
Mosocho
Keumbu Kiogoro
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Methods• Kisii District, Nyanza Province (population 4.7
million; target population 5000)• September 2009 three days day, three site
campaign• Campaign objective:
– Lessons from the 2008 Kakamega campaign– Feasibility of scaling up onsite CD4 cell counts – Testing the campaign in a peri-urban setting – Determine potential benefits of early HIV
identification• Interventions:
– LLIN, water filters, 60 condoms– Health education information
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Methods: logistics and laboratory• Ministry of Health and Vestergaard Frandsen collaboration• Participants with HIV received a 3-month supply of
cotrimoxazole and referral for further care and treatment• Campaign cohort used Guava AUTOCD4 flow cytometers
for CD4 counts • Hospital reference cohort used Becton Dickinson FACS
Calibur• External quality control of CD4 counts
– 5% campaign samples sent to Kisii Hospital for quality control
– Kisii hospital works in partnership with CDC Kisumu for quality control of CD4 counts
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Methods: Hospital cohort
• Kisii Hospital 6 month historical reference cohort abstracted from medical records (March to August 2009)
• First CD4 counts of all patients aged 15 and above diagnosed with HIV
• Historical cohort of 1284 patients• Modeling of potential benefits was done using
similar parameters and model – 2007 KAIS CD4 data
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Results– Campaign reached 5203 individuals
• Package given to 5203 (100%) of people whether or not they decided to have HIV test
• 100% tested for HIV• 329 (6.3%) tested HIV positive• 255 (78%) had CD4 count determination • median of 536 cells/ µL (IQR 350;759)
– Kisii Hospital reference cohort• 1284 first CD4 counts • Median 348 cells/ µL (IQR 185;551)
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CD4+ cell count distribution in Nyanza Province (KAIS survey) and the Kisii campaign
0.0
0.1
0.2
0.3
0.4
0.5
0-250 250-500
500-750
750-1000
1000-1250
1250-1500
1500-1750
1750-2000
Nyanza and Campaign Nyanza Province (KAIS)Campaign participants
No significant difference in the distributions
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CD4+ cell count distribution in Nyanza Province (KAIS survey) and the Kisii campaign
hospital cohort
0.0
0.1
0.2
0.3
0.4
0.5
0-250 250-500
500-750
750-1000
1000-1250
1250-1500
1500-1750
1750-2000
Nyanza and ReferenceNyanza Province (KAIS)Kisii Hospital reference cohort
Hospital cohort significantly lower
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CD4+ cell count distribution in Kisii hospital reference cohort and the Kisii campaign
0.0
0.1
0.2
0.3
0.4
0.5
0-250 250-500
500-750
750-1000
1000-1250
1250-1500
1500-1750
1750-2000
Reference and Campaign Kisii Hospital reference cohortCampaign participants
Campaign cohort significantly higher
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0.00
0.20
0.40
0.60
0.80
1.00
0 500 1000 1500 2000CD4/micro-litre
Cum
ulat
ive
prob
abili
ty
ReferenceCampaignKAIS (Kissii)
Hospital referenceCampaignNyanza (KAIS)
CD4+ cell count frequency distribution (Hospital reference, Campaign, KAIS)
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Modeled impact of campaign approach for Nyanza Province
Percent of HIV positive population
Number started on ART
EstimatedHIV transmissions averted
Deaths averteddirectly
TB cases averted per year
CD4< 200 8% 24,000 5,000 24,000 2,400
CD4 <350 26% 76,000 27,000 76,000 3,600
Immediate 90% 268,000 241,000 268,000 4,700
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Conclusions
• Integrated campaigns have a significant potential to bring services to people where they live– Possible to bring CD4 technology to the community
• Improved access translates into earlier HIV diagnosis
• Early HIV diagnosis has significant prevention, care and treatment benefits
• To reach Universal Access and achieve MDGs we will need to expand access to HIV services in the community
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People of Kisii town and surrounding areas Nicolas Muraguri (MoH Kenya)Alex Doyen (Vestergaard Frandsen)Navneet Garg (Vestergaard Frandsen)Brian Williams (SACEMA)MoH Kenya staffVestergaard Frandsen
Thank you
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Public health is purchasable. Within a few natural and important limitations any community can determine its own health.
--Hermann M. Biggs(29 Sep 1859 - 28 Jun 1923)New York City's Public Health Officer and public health pioneer