Expansion of HIV programme
services over a five year period in a high HIV prevalence area of rural Kenya resulted
in close to a third of HIV-positive adults getting care and over 60% starting
ART, coinciding with a 30% decline in overall adult death rates according to an
analysis of health, demographic and mortality data published in the advance
online edition of AIDS.
Death rates at the population
level for AIDS and tuberculosis declined by 26% and 47% for other infectious
diseases, but remained at the same level for non-infectious diseases. This
would suggest an infectious disease intervention, note the authors.
Rapid scale-up of HIV
services and the provision of ART in sub-Saharan Africa have resulted in
improved health and fewer deaths. The effect at the individual level is well
documented. A few studies in sub-Saharan Africa have shown that with the
establishment of ART programmes population adult death rates have
declined. These studies have described
patient characteristics at the time of enrolment and how they relate to access,
retention and survival.
The authors suggest by looking
at changes in demographics or clinical status of patients during scale-up may
help gain a better understanding of the impact of HIV care and treatment at the
population level in a defined geographical area.
With an HIV prevalence of
14.9%, the rural Nyanza Province in western Kenya is the highest in the
country. Approximately 500,00 people are living with HIV/AIDS. High rates of
malaria and tuberculosis are also prevalent.
In 2003 HIV care and ART
services were established and expanded over a five-year period. Since 2001 a
Health and Demographic Surveillance System
(HDSS) maintained by the Kenya Medical Research Institute in
collaboration with the US Centers for Disease Control and Prevention have
recorded population characteristics and death rates from approximately 140,000
residents within Nyanza Province.
The authors linked adult HDSS
HIV clinical records to population level HDSS demographic and mortality data to
describe uptake of HIV care and ART and its effect upon changes in adult death
rates in a time of rapid expansion of HIV services in Nyanza Province.
They also chose to describe changes
in (socio-demographic) enrolment and clinical characteristics among patients
(pre-ART and ART) during this time and so identify trends. The authors believe
this to be the first time this has been explored.
In 2003 11 DHSS residents
were documented as enrolled in HIV care at one health facility. The numbers
rapidly increased. From 2003 to 2008 a total of 5421 HDSS residents had
enrolled in HIV care. 3331 (61.4%) were linked to HDSS follow-up data. Health
facilities had increased to 17 of which 70% (12) offered ART. HIV positive
residents getting HIV services rose from under 1% to close to 30%. ART coverage
(CD4 cell counts under 250 cells/mm3) rose from less than 1% from
2003 to 2005 to 6.6% in 2006 to 64% in 2008.
The proportion of those being
referred from voluntary counselling and testing sites decreased while other
clinic-based referrals increased. Six percent were referred from prevention of
mother to child transmission (PMTCT) programmes and antenatal clinics (ANC).
Median distance from the
residence to the clinic decreased over time (4.4 km IQR: 2.4-8.1 km to 3. 2 km,IQR:
2.2-5.7 km, p <000.1). The proportion of those with WHO clinical stage 4 at
enrolment fell from 20.4% to 1.9% while CD4 testing at enrolment increased from
1% to 53.4%, p<000.1.
Decentralisation of services
enabled patients to access care closer to home. As expansion of services
increased so did system efficiencies resulting in better quality of care. CD4
testing became available and reduced time to start of ART. So patients
presented earlier in the course of their illness.
The proportion of patients in
HV care with a primary education or less and those with home access to safe
water increased significantly, 71.9 to 79.3, p=0.01 and 18.1 to 31.2,
Most patients (92.9%) were
getting cotrimoxazole (CTX) prophylaxis.
ART has been shown to reduce
the risks of transmission. In addition, other components of HIV care (CTX
prophylaxis, better access to safe water compared to the general population in
this study, TB screening) while reducing the risks of death and disease in the
individual might also have benefitted the family and community. So the overall
effect at the population level would be greater than the sum of individual HIV
Adult death rates dropped by
a third during this time of rapid scale-up.
The researchers note while
there is no direct relationship between expansion of HIV services and
population decline in death rates it is the most likely reason.
Health interventions in place
at the time were focussed on pregnant women (malaria prevention initiatives)
and reducing under five death rates. No other significant health interventions
were in place.
The greatest decrease in
death rates was among those age groups with the highest HIV prevalence. Deaths
from non-infectious diseases did not decrease implying an infectious disease
intervention, the researchers add. In addition, these findings are consistent
with other studies in high prevalence areas of sub-Saharan Africa where
AIDS-related death rates dropped considerably following widespread ART
A key strength of the study
is the linkage between clinic data and population surveillance allowing the
authors to look at declining death rates at the patient and population level.
While PMTCT services grew
during this time referral was low (5.1%) and very few women (25) reported PMTCT
ARV prophylaxis. Even though clinical status at enrolment improved from a
median of 192 (IQR: 111-279) cells/mm3 in 2005 to 256 (IQR: 130-457)
2008 (p=0.007), it was still low with 44% qualifying for ART at enrolment.
The authors conclude “efforts
to identify HIV-positive individuals earlier and achieve rapid enrolment into
clinical care with high rates of retention and ART adherence are warranted to
optimise individual and population-level benefits of HIV care and ART