Core Problem 1: New HIV Infection.

While remarkable progress has been made to reduce New HIV infections, in 2022, Kenya had 22,154 new HIV infections translating to 426 new HIV infections in a week. About 60% (13,305) of all the estimated new HIV infections occurred among adults aged between15 to34 withfemalesaccountingfor 72%(9,627) of these infections. Additionally,childrenaged0-14 accounted for 20.19% (4,474) of all the estimated new HIV infections. In addition, Geographical disparity still exists with 9 counties accounting for 50.2% of the new HIV infections in Kenya.

To achieve zero new infection by 2027, efforts must be put towards identification of the remaining unidentified people, puting clients at ongoing risk on prevention while ensuring those on treatment are virally suppression.

 Root Causes

1.     Gap in identification among Children and Adults: As at end of 2023, 96.8% of the estimated PLHIV had been identified and linked to treatment Leaving the country with the challenging task of identifying, initiating and retaining the remaining 50,000 people on ART. AYP, Adolescent, Children and men are lagging in identification at 68.1%, 82.9%, 86.9% and 90.1% respectively. Further, county disparity in identification was evident with 12 counties achieving less than 72% in identification as at end of 2023.

2.     Sub-Optimal linkage to HIV Prevention: Despite great progress realized over the past decade, including initiating over 400,000 clients on PrEP, the program continues to see sub-optimal linkage to HIV prevention. For the 5.9M at risk population testing HIV negative in 2023 only 5% were linked to a biomedical intervention.

3.     High Mother to child transmission (MTCT): While the country has recorded a decline in MTCT rate from 14% in 2013 to 8.6% in2023, Kenya is yet to achieve the MTCT goal of 5% resulting in about 12 children acquiring HIV on daily basis. The contributors to this pattern of high MTCT rate are persisting delays in HIV diagnosis, delay in antiretroviral treatment (ART) initiation and sub optimal adherence during pregnancy and breastfeeding that have resulted in 4,456 infants acquiring HIV in the past year.

Program Intervention to reduce HIV New Infection:

To close the gap on New HIV infection, program with the support of CHAI is implementing the following intervention:

1.     Testing for prevention and identification. The strategic shift from conducting an HIV test for identification to testing for both prevention and identification (Status Neutral Testing). In this approach HIV test spurs action regardless of the result by recognizing the opportunity created by a negative or positive result for an individual to achieve better health outcome.

Figure 2: HIV status Neutral Delivery model

2.     Market shaping to increase access for HIV self-testing: While Kenya rolled out HIVST in public sector in 2018, the high prohibitive cost of oral kits has limited the country from fully leveraging on the benefits of HIVST. Further, the population lagging in identification-AYP, Adolescent and men – have poor health seeking behavior and HIVST will enhance uptake of testing among them.

3.     Introducing new biomedical intervention such as Dap Virginal Ring, Cabotegravir to increase choice to the client as well as address pill burden.

4.     Enhancing HIV Testing for all mothers and their partners at 1st ANC,3rd Trimester, L&D and PNC to ensure timely identification and linkage to prevention.

5.     Data and Data Use to ensure continuity of quality HIV testing services, CHAI will continue to use programmatic and commodity data to support the ministry in making informed decision making.

Core problem 2. Mortality.

 An estimated 18,474 AIDS-related deaths occurred in 2022, a decline of 17.4% from 22,373 in 2021. There were 16,159 AIDS-related deaths among adults aged 15 years and older (8,538 among female and 7,632 among male), representing 88% of the total 18,453 annual AIDS-related deaths in 2022. Despite this, in relation to male population, more males are dying (2%) as compared to female population in relation to female population (1%). There has been a 2.5% decline in adults AIDS-related death in the past three years from 16,572 in 2019 to 16,159 per year in 2022. Ten counties accounted for more than half (51%) of adult deaths in 2022, namely, Kisumu (1,238), Homa Bay (1,155), Nakuru (937), Siaya (927), Nairobi (887), Migori (725), Mombasa (707), Kakamega (604), Uasin Gishu (581), and Kiambu (502).

 While there is a decline in deaths for the entire HIV population, Paediatrics continue to contribute a significant number of HIV related mortality. In 2022, HIV deaths among 0-14 was estimated to be 2,305 accounting for 12.5% of all AIDs related deaths. Of concern, 1,711 of the children die before their 4th birthday attributing to 75% on all the deaths for children below 15 years.

 The goal of HIV program

 Reduction of mortality to zero by 2027.

 Root cause

 1.     Treatment Failure: Currently, 6.3% of all the patients on ART are suspected to be failing on treatment of which 21.7% are confirmed to fail. This accounts to about 30,000 patients per year.

2.     Interrupted in treatment: Despite great efforts and reduction over time, Interruption of treatment has continued to be a main problem for PLHIV identifies. Currently approximately 40,300 (3.1%) interrupted treatment in 2023. This is a decrease from 5.6% in 2022. This may lead to may result in viral rebound, immune decompensation, and/or clinical progression.

3.     Late into care and suboptimal baseline investigations: Approximately 30,561 (30%) of the population come into care present with advanced HIV disease. Out of all clients initiated on treatment only 19% received a baseline CD4 test. This leads to death of such clients that have Advanced disease due to conditions such as IRIS.

4.     Aging with HIV: About 404,000 (32%) clients on ART above 50 years of age. Data shows that just about 40.5% of these clients have an eGFR < 60 mL/min/1.73m2 persisting for more than 3 months (signs of chronic kidney disease). Treatment for comorbidities among these clients is common, with 24.5% on treatment for hypertension and 5.5% on treatment for diabetes mellitus.

Effects of root causes

 1.     Advanced HIV Disease (AHD): People presenting with advanced HIV disease are at high risk of death, even after starting ART, with the risk increasing with decreasing CD4 cell count, especially with CD4 cell count <100 cells/mm3. In Kenya, more than 30%and15%of allAIDs relatedmortality amongPLHIVsaredirectly attributable toTB andcryptococcal meningitisrespectively. Of concern, only 30% of cryptococcal meningitis patients survive.

2.     Chronic kidney disease is associated with increased health-care costs among PLHIV with such a condition.

3.     NCDs: An estimated 883,694 of the 1.4 million PLHIVs are aged 35-74 years. PLHIVs are at a heightened risk of acquiring NCDs due to increased inflammatory markers and associated adverse effects of ARVs. The cohort of aging people living with HIV is likely to significantly contribute to NCDs’ burden in the absence of interventions.

Progress made in 2023

 1.     AHD

•     Mapping and optimization of the CD4 testing to improve baseline CD4 testing. This has moved testing for CD4 from 50,359 to 96,964 leading to 92.5% increase.

•     CM testing among the PLHIV with a CD4 below 200 cells/mm3 has increased from 26,918 to 31,095.

•     CHAI in collaboration with the ministry of health, NASCOP, has worked on the inclusion of 5FC and AmBisome in quantification and have received product commitment for the products in COP 23. The use of this product will start in the second quarter of this year.

2.     Chronic Kidney Disease: CHAI in collaboration with CHAI and other stakeholders are working on introduction of TAFLD regimen to replace TLD first among the aging as we move to fully replace TLD with an aim of eliminating Tenofovir Disoproxil Fumarate (TDF) which is the major cause of kidney injury.

3.     NCDs- integration of cancer, diabetes and hypertension screening among PLHIV has been the focus of the program in 2022/23.