Towards the last 90% of the 90:90:90 strategy: A review of viral suppression rates in a HIV program in Central and Eastern Kenya Dr Moses Kitheka, Chief of Party, Jhpiego Kenya 21st International AIDS Conference, Durban, South Africa. 20th July 2016

Background - HIV in Kenya 2013: Estimated 1.6 million PLHIV, (191,840 Children). Estimated 101,560 New Infections Kenya adopted 90:90:90 approach in programing and implementation Key Documents:- National plan for Accelerating HIV Care and Treatment & Kenya AIDS Strategic Framework Viral Load testing for routine treatment monitoring since mid 2014

Kenya AIDs Strategic Framework 2014/15- 2018/19

Main Objective To review the Viral suppression rates in samples submitted for viral load testing by APHIAPLUS KAMILI from January 2015 to December 2015

Project background Led by Jhpiego, APHIAPLUS KAMILI is a USAID funded project supporting HIV services in 142 health facilities since January 2011 Total of 35,120 clients on ART (3,332 children) as at December 2015 Viral load monitoring done through specimen collection at facilities, processing and sample transport network to National laboratories Results posted online immediately, then physical results send to the health facilities

What have we done? Clinical and laboratory staff trained on clinical and laboratory management/monitoring of HIV patients Commodity support- EDTA Tubes, CryoVials, request forms etc. On site Technical Assistance and Mentorship Logistical Support for laboratory transport of specimen to central laboratories SOPs and Job Aides

Methods for analysis Retrospective, cross sectional analysis of VL results on all specimens send for VL testing with results posted online from January 2015 to December 2015 Source: Results of viral load tests posted online – www.nascop.org/eid Used the R-Statistical software Viral suppression defined as Suppressed: VL < 1,000 copies/ml Not suppressed: VL ≥ 1,000 copies/ml

Progress in Viral load testing

Results Total Viral load results analyzed-24,030 Crude Viral Suppression rate 84% Viral suppression analyzed in different different categories

Viral Suppression by Sex (N=22,244) Base: Female Multivariate: No significant difference p=0.475

Viral Suppression by Age (N=21,293) Base: Age Above 25 years Bivariate- p<0.001 for all Multivariate: Same for all

Suppression by Duration on ART (N=16,387) Base 7-12 months Bivariate: Age 0-6 Months p=0.007 .the rest are not significant Multivariate: No significance

Suppression based on Indication for VL testing (N=17,264) Base: Routine VL Bivariate: significance at clinical failure p-0.017 Multvariate: Clinical failure significanp p=0.00958

Conclusion Fairly good viral suppression rate, yet to reach 90% Viral load testing is important in monitoring treatment and program success Females have better viral suppression than males Viral suppression lower in younger clients, especially adolescents, and better in those above 25 years of age Clients identified with possible clinical and immunologic failure had fairly good viral suppression

Way forward Need to address the other 90s to complete the cascade Re-evaluate adolescent care cascade to improve adherence and enhance quality of care Need to intensify routine viral load monitoring as a way to better monitor treatment success and adherence Clients not suppressed - Adherence counselling and treatment monitoring for treatment failure

Acknowledgments USAID Ministry of Health, Kenya County Governments All health care workers Communities

Suppression by ART regimen Base: TDF/3TC/EFV Bivariate: Significance in all except AZT/3TC/ABC, AZT/3TC/ATVr, Multivariate: Signifiant for AZT/3TC/NVP, TDF/3TC/ATVr, etc

Analysis….. Bivariate Multivariate Variable Odds ratio 95% CI p-Value   Bivariate Multivariate Variable Odds ratio 95% CI p-Value Gender: Female 1.155310 1.071624 1.245037   <0.001 1.038782 9.353127 1.152732 0.475 Age: 25+ yrs 0-2 3-5 years 6-15 years 16-24 years  0.30921090.76113460.38089710.4337557   0.2514118 0.3819088 0.6827425 0.8499619 0.3422494 0.4243185 0.3701587 0.5099633 0.3107823 0.8088518 0.4375439 0.4423663 0.2338842 0.4154402 0.6992667 0.9384978 3.732135 0.5139438 3.598326 0.5468909 0.00470 Failure: Routine Clinical failure Immunological Pregnant Drug substitution 0.8126852 0.8954680 0.4926617 0.8513646 0.6864359 0.9671582 0.7490235 1.0772142 0.2756365 0.9266037 0.6842442 1.0694594 0.0177 0.2333 0.0211 0.1574 0.7652473 0.8006715 0.4015799 0.8661054 0.6270862 0.9403572 0.6478412 0.9975698 0.1970350 0.8837200 0.6621947 1.1488518 0.00958 0.04333 0.01593 0.30570 Duration: 7-12 Months 0-6 13-24 25-60 61-120 120+ 0.7648131 0.9221004 0.8884153 0.9441058 1.0765524 0.6548628 0.8944595 0.7989797 1.0649867 0.7857829 1.0039129 0.8359107 1.0656854 0.7159117 1.6833947 0.000746 0.268500 0.058287 0.353110 0.734196 0.9380002 0.9033947 0.8754164 0.9576521 0.9643734 0.7728074 1.1420984 0.7633619 1.0700490 0.7562161 1.0126393 0.8240357 1.1120966 0.6109829 1.5901838 0.52043 0.23816 0.07399 0.57145 0.88128

Regimen: TDF/3TC/EFV ABC/3TC/NVP ABC/3TC/ATVr ABC/3TC/EFV ABC/3TC/LPVr AZT/3TC/ EFV AZT/3TC/ NVP AZT/3TC/ABC AZT/3TC/ATVr AZT/3TC/LPVr TDF/3TC/ATVr TDF/3TC/LPVr TDF/3TC/NVP   0.2691723 0.2354170 0.4187483 0.3178912 0.6903214 0.6715426 0.7490540 0.5243378 0.7438881 0.4681588 1.4481710 0.8655444 0.21389489 0.3401185 0.09246745 0.6412982 0.32404824 0.5460736 0.21932888 0.4681609 0.57911213 0.8266761 0.60983166 0.7392889 0.12062118 14.3602008 0.18759812 1.8530298 0.50386437 1.1365604 0.21984449 1.11262514 0.91240498 2.4475873 0.77263210 0.9702518 <0.001 0.00285 0.79207 0.25577 0.15243 0.06275 0.13888 0.01293 0.4839887 0.4233561 0.7648243 0.6262169 0.7616974 0.7325590 6086.4047336 2.2562784 0.9480684 0.2903689 1.52.2067 0.8254543 0.3572243 0.6593847 0.1172464e-1.7013207 0.5481377 1.0796118 0.3888611 1.0377211 0.6107141 0.9562366 0.6444614 0.8326012 NA 0.4381080 41.3734034 0.5777765 1.6435743 0.11934410.7744861 0.8649215 2.9335050 0.7156485 0.9529132 0.19392 0.12047 0.06055 0.01724 0.94186 0.43707 0.84062 0.00838 0.17506 0.00862