Background

Efforts over the last decade have demonstrated great progress: over 1.29 million PLHIV are receiving ART out of the estimated 1.43M, and AIDS-related deaths have decreased by 40% since 2013. Efforts to reduce new HIV infections have helped achieve significant gains, with 65.9% fewer HIV infections since 2013. CHAI played a significant role in helping the country to get where it is today by catalyzing treatment access for both adults and children, championing for introduction of effective prevention methods, scale up of Viral load for patient monitoring and Optimization of HIV testing strategies.

Despite remarkable progress and country commitments, we risk failing to reach epidemic control as started on the vision 2030. Although ART scale-up to date has helped decrease incidence rates in Kenya, there were still 34,540 new infections in 2022 an increase from 32,027 in the previous year. Kenya faces the challenging task of identifying, initiating, and retaining more than 130,000 new people on treatment in the next few years, as well as scaling up effective and targeted prevention interventions.

CHAI believes that a targeted approach to testing, treatment, and prevention while strengthening linkage and retention across the cascade of services will enable countries to identify and treat the vast majority of PLHIV and prevent new infections. We are committed to continue working with MOH to reach the country’s goals in controlling the epidemics, defining approachs within the ‘Test Smart, Treat Right, Stay Negative’ Strategy:

Test Smart, Treat Right, Stay Negative Strategy

Test smart

Identifying and linking the remaining PLHIV is the primary limiting factor to ART scale-up, and currently the largest gap across the 95-95-95 cascade. As treatment coverage increases, the number of PLHIV not yet on treatment will decrease and become harder to find. Given these dynamics, data-driven, targeted testing becomes increasingly critical in terms of cost and resource efficiency. Current testing strategies are not reaching all those at risk. CHAI has continually worked with the NASCOP and NSDCC to streamline testing strategies

·        CHAI has being keen in optimization of testing strategies. The introduction and scaleup of existing testing strategies that work, such as universal testing in high-yield facility entry points, index testing and HIV self-testing. This was amidst reduction of investment in testing from the initial 14 million to 4 million tests by PEPFAR. The introduction and scale up of these interventions has allowed the country to achieve a steady identification trend and has propelled the country in the direction of achieving the first 95% target. CHAI has also lead a stakeholders discussion on a paradigm shift from testing for identification to testing for prevention an engagement that gave birth to integration of testing into HIV prevention. This has led to an increase in the uptake of prevention services which consequently led to an increase in the commitment of procurement of kits for 700,000 to 10 million by PEPFAR.

·        Point of care testing for EID was key for testing of children at their point of contact.

However, despite all the successes there remains a gap of 130,000 of PLHIV yet to be identified. There are still opportunities to optimize existing strategies because what got us here will not get us to where we need to go, and we need to continue to innovate to reach those currently left behind.

Treat Right

To maximize retention and viral suppression in the context of significant scale-up, programs must get three elements of treatment right: treatment regimens, the identification of and response to treatment failure, and service delivery models. CHAI has continually worked with NASCOP to achieve this through the following steps:

1.      Scale up access to better regimens: Providing patient access to optimal ARV regimens is critical to achieving and maintaining viral suppression, as well as reducing morbidity and mortality. Regimens that are easy for patients to take with limited side-effects and toxicities, and have a greater barrier to resistance, promote treatment adherence and better treatment outcomes, as well as reduce the need for more toxic and costly second- and third-line therapies. Kenya became the first country to roll out generic DTG when it began transitioning patients in 2017. This was followed to the introduction of pediatric DTG to cover the peds who where taking LPV/r which was unpalatable and expensive. As a result of this, 99.4% and 94.1% of all the first line adults and pediatrics respectively are on the most optimal regimen. This has made the country to achieve a viral suppression rate of above 96% for all the PLHIV.

2.      Scale up access to viral load testing to ensure prompt, appropriate response to viral failure. Achieving viral suppression is critical for both patient health and preventing transmission, and regular VL testing can act as an incentive for patients to strive for adherence. Despite several challenges on Viral load testing, Kenya has continually managed to offer at least one Viral load test to a patient per year. In addition to this the Turnaround time for Viral load result has reduced significantly to an extent where some patients are able to access their viral load results the same day for the point of care testing.

Leveraging of existing technologies: Build national consensus for integrated testing of HIV and TB on GeneXpert platforms (support to both EID and VL work). This has broadened our testing scope for Viral load.

Despite this great achievement, decision making using the data to confirm failure for switching has not been followed keenly. This has led to some patients staying for long on a regimen they are failing.

3.      Rapidly transition to efficient, patient-centred models of care. Models like multi-month scripts, fast track refills, and community ART groups can improve retention for patients on ART by reducing the burden of lengthy, frequent facility visits for stable patients. The Country has made Great steps towards patient centered care delivery model. CHAI has been at the center stage advocating for the move towards prioritization of patient needs over service. This has led to services being moved to the community through DSD delivery. However, this is yet to be optimized as currently only 39.5% of the patients are enrolled to some form of an ART group. Approximately 56% of the patients are still utilizing the standard track service delivery. As shown below.

While we have made remarkable progress with treatment scale-up to date and have achieved high Viral load coverage and suppression, high access to optimal regimens, highly palatable and low-cost medicine, we still have a population not suppressing, dropping off care and PLHIV presenting to treatment with WHO stage 3 or 4. This has created two Major problems that has affected the country’s progress towards reduction of mortalities and new infections

A.   Advanced HIV disease

According to NDWH and Kenya Viral load dashboard:

·        Approximately 30% of newly enrolling PLHIV in Kenya have Advanced HIV Disease.

·        Of all the viral load routine tests done, 5.7% of patient are suspected to be failing treatment and 5.1% having a low-level viremia.

·        Out of all the test done to confirm failure and PLLV, 21.7% was confirmed to be failing.

For the proportions above, patients who are confirmed to be failing treatment are 30,189 as show in the table below;

According to KHIS about 26,000 people identified monthly and linked to ART. Approximately 30% of this population is estimated to be failing treatment. This accounts for 7,800 AHD cases per month. Overall, about 37,989 cases of AHD cases per month witnessed in Kenya. 

Despite the high cases of AHD, Kenya has had issues in Identification and management of this cases. This has been caused by deprioritization of CD4 testing, and lack of optimal regimens to manage major OIs like immune reconstitution inflammatory syndrome, tuberculosis (TB), severe bacterial infections, cryptococcal disease, histoplasmosis, toxoplasmosis, and Pneumocystis Jirovecii pneumonia amongst others.

B.   HIV Drug resistance (HIV DR)

Kenya has made significant progress in the fight against HIV DR; however, there is increasing transmitted drug resistance (TDR) prevalence rates, as we have seen from the threshold survey among prima gravida women aged <25 years presenting in 12 anti-natal clinics (ANC) in two regions of the country (Kisumu and Nairobi) between 2008 and 2010. Although HIV DR prevalence seems to have stabilized, studies conducted in Kenya put pre-treatment drug resistance (PDR) rate close to the 10% WHO cut-off threshold of NNRTI DR rate. The current Guideline has recommended HIV DR testing for the patients failing treatment. However, Kenya being resource constrained, there has not been a clear algorithm on management of patient failing on treatment. This has led to blind switching of patients without considering the drug susceptible to. This has led to CHAI advocating for a switch that is guided by a DR test. Currently, the country has about 32,068 patients in need of a DR testing. this patients falls into the following category;

• When a clients repeat viral load with is ≥1000 copies/ml if the routine Viral load was a suspected failure(≥1000 copies/ml)
• When a client’s repeat Viral load is ≥1000 copies/ml, if the routine Viral Load had an increased risk of progression to treatment failure ( VL 200-999 copies./ml).

The goal we wish to achieve with DR testing is to avoid an increase number of second line and third line patients therefore reducing treatment cost, pill burden, and mortality.

Stay Negative

Over the past decade, Kenya achieved overall 65.9% Reduction of New HIV Infection through adoption and implementation of a number of prevention interventions

• Coordinated targeted scale-up of currently available prevention options- CHAI has been in the center of introduction of PrEP and leading conversation on integrated service delivery of HIV prevention methods. PrEP uptake has increased to about 250,000 initiated on PrEP.
•  Testing for prevention. Paradigm shift from testing for identification to testing for prevention has been key in increasing the population eligible for HIV prevention. This has led to the justification of investment case for the PEPFAR agents a thing that has led to increased funding for the HIV testing commodities from previously 700,000 tests for first assay to 10,000,000.
• Priority has been on linking the positive to care. Linkage to prevention has continually posed as a gap over time. For the 3.5M at risk population testing negative HIV prevention should be offered to increase our prevention base.
• · Integration of HIV prevention with SRH will play a pivotal roll in covering the prevention gap and at the same time responding to the FP need.

Summary Of issues highlighted above under each of these thematic areas

Service Delivery

Issue

1. Implementation plan on AHD not yet developed
2. OI manual out of date

Intervention

1. Collating and processing all the materials relating to this subject to share with the Stakeholders for decision making
2. Providing analytics on AHD to the program to create AHD baselines implementation purpose.
3. Help with design of tracking tools for tracking different interventions (give examples of interventions that Gates want us to report about.
4. Updating the OI manual/ development of An AHD implementation manual

Supply chain

Issue

1. Core AHD products either not in the guidelines or not registered in country
2. CD4 sample network missing
3. DRT tests not available

Intervention

1. Inclusion of CD4 testing in the quantification. Both conventional and lateral flow.
2. Develop a plan that includes treatment of major IO and optimal treatment regimens.
3. Quantify for the key commodities including CD4, TBLAM, TPT, 5FC, L-AMB
4. Map the 376 conventional CD4 testing site
5. Introduction of point of care lateral flow
6. Price negotiation for DRT
7. Mapping resource needs for DRT
8. DRT decentralization
9. Sample network mapping
10. Resource mobilization for DRT testing
11. Utilization of DRT data for patient sequencing and optimization.

Data and Data Use

Issue

1. No indicators for CD4 testing
2. No indicators for screening and treatment of Major OIs except TB
3. No data on mortality audit for HIV

Intervention

1. Update EMRs to capture AHD data
2. Scale up EMRs through partners (CDC, USAID partners) and GF RSSH
3. Update the physical tools: MOH 371
4. Enhance reporting for AHD in NDWH and CBS
5. Continuous data analysis to inform programming.