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Tom Oluoch, on behalf of the KAIS TWG March 2 nd , 2009 Bangkok, Thailand. Utility of additional biologic tests in a nationally representative HIV survey. History of HIV Surveillance in Kenya. Antenatal sentinel surveillance 1990-2006 (currently 43 sites)

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tom oluoch on behalf of the kais twg march 2 nd 2009 bangkok thailand

Tom Oluoch, on behalf of the KAIS TWGMarch 2nd, 2009Bangkok, Thailand

Utility of additional biologic tests in a nationally representative HIV survey

history of hiv surveillance in kenya
History of HIV Surveillance in Kenya
  • Antenatal sentinel surveillance 1990-2006 (currently 43 sites)
  • STI patient sentinel surveillance 1990-2006
  • National Demographic and Health Surveys 1998, 2003 with HIV finger stick testing
  • AIDS Indicator Survey 2007 with venous blood draw
    • 1st AIS
    • 2nd pop-based HIV sero-survey, in Kenya
kais design
KAIS Design
  • Stratified two-stage cluster sample design
    • 8 provinces, urban and rural areas
  • Eligibility:
    • HH sample: usual residents/visitors night before survey
    • Individual sample: Men and women age 15-64 from participating households
  • Reported estimates weighted to account for sampling
  • Informed consent for interview, blood draw, sample storage
utility of hsv 2 and syphilis data
Utility of HSV-2 and Syphilis Data
  • Monitor known risk factors for acquisition and transmission of HIV infection
    • Syphilis (associated with 2.5 times increase in HIV prevalence)
    • HSV-2 (associated with 8 times increase in HIV prevalence)
  • Results imminent on the effects of treatment of people with HIV/HSV-2 co-infection to prevent HIV transmission– Kenya is a trial country.
  • Inform upcoming revisions to STI clinical management guidelines
utility of cd4 data
Utility of CD4 data
  • In this era of prevention, care & Rx scale-up, HIV status, knowledge of status, ART use and CD4 are necessary to interpret the epidemic
  • Guiding policy decisions on treatment
  • Estimating current and future need for care and treatment.
  • Additional information on new and old HIV infections.
  • Planning resources for care and Rx.
national repository for future testing
National Repository for Future Testing
  • DBS, serum and clot specimens stored at -80oC
  • >99.9% of participants consenting to blood draw, also consented to storage
  • Resources and policies required upfront to guide ownership, access and use.
  • Potential Utilization:
    • Monitoring drug resistance over time
    • Looking at HIV incidence
    • System strengthening for the country (other infectious and non-infectious diseases).
new questions on status and behavior
New Questions on Status and Behavior
  • Knowledge of HIV status - self and sexual partners
    • 98% of those ever tested for HIV agreed to disclose result of last HIV test
  • Partner specific behavior, including partner status and disclosure between partners.
  • When used with other indicators (condom use, lab confirmed HIV status), these new questions help to identify important gaps in services and patterns of acquisition and transmission
  • History of use of Cotrimoxazole and ART
overall response rates
Overall Response Rates

Households interview: 97%

Individuals interview: 91%

Blood draw: 80% (88% of those interviewed vs. 77% in DHS 2003)

Sample size for analysis:

  • 9,691 – households
  • 17,940 – individual interview
  • 15,853 – blood draw
hiv prevalence by gender
HIV Prevalence by Gender

2007 KAIS indicates that 7.1%, or about 1.3 million Kenyans age 15-64 are infected with HIV.

hsv 2 prevalence co infection
HSV-2 Prevalence & Co-infection
  • National prevalence: 35.1%(6.7 million adults, 15-64)
  • HIV was 8 times more common in HSV-2 infected than HSV-2 uninfected persons (16.4% vs. 2.1%)
  • 80.7% of HIV-infected persons were infected with HSV-2, 2.5 times the prevalence in HIV-uninfected persons (31.6%)
syphilis prevalence co infection
Syphilis Prevalence & Co-infection
  • National prevalence: 1.8%(342,000 adults, 15-64)
    • Women: 1.7% Men: 1.9%
  • Syphilis was 2.5 more common in those with HIV-infection than HIV-unifected persons (4.2% vs. 1.6%)
  • 16.9% of HIV-infected persons were infected with syphilis, 2.5 times the prevalence in HIV un-infected persons (6.9%)
knowledge of hiv status among hiv infected kais participants
Knowledge of HIV Status among HIV-infected KAIS Participants

16% knew they were positive

56% never tested for HIV

28% reported last HIV-test negative

84% of HIV-infected adults did not know their status.

Denominator: Lab-confirmed HIV infected participants (2% missing data on HIV testing history or known HIV status; 1% chose not to disclose status)

coverage of cotrimoxazole
Coverage of Cotrimoxazole

12% Know status, on CTX

Among those who knew their status, 75% on cotrimoxazole

4% Know status, not on CTX

84% Unaware of status*, not on CTX

Denominator: Lab-confirmed HIV infected participants

* Never tested for HIV, reported uninfected based on last HIV test

coverage of art among eligible hiv infected persons
Coverage of ART among Eligible HIV-infected Persons

Among those who knew status and were eligible, 92% on ART

39% Know status, on ART

57% Unaware of status*, not on ART

4% Know status, not on ART

Denominator: Lab-confirmed HIV-infected persons with CD4<250 and not on treatment plus those who reported ART use * Never tested for HIV, reported uninfected based on last HIV test

cd4 cell count distribution among hiv infected adults not on art
CD4 Cell Count Distribution among HIV-infected Adults not on ART
challenges
Challenges
  • Syphilis: Interpretation of results presents challenge. Visual interpretation is subjective.
  • Developing counseling messages on HSV-2 used for returning results to participants.
  • Careful planning for logistics: sample transportation and short turn-around time for CD4 testing (7 days).
  • Timely return of results to participants
conclusions
Conclusions
  • HSV-2 and syphilis remain major risk factors in HIV acquisition among Kenyan adults
  • Biologic indicators, used together with behavioral data are necessary for interpreting the epidemic.
  • Critical for policy and program planning
  • Its feasible in diverse geographic region
  • Additional biological indicators did not negatively impact participation rates