1. Evidence for optimizing highly active antiretroviral treatment (HAART) in Kenya Dr. Washingtone Ochieng CNHR RCDG Fellow returning from Harvard University, U.S.A Research Host: CREATES

2. Summary: HIV Prevalence & treatment Declining prevalence, rising numbers! Longevity- ART More PLWH TREATMENT ARV access improved Monitoring not so Adherence & failure Study sites

3. Relevance to Policy Great progress at controlling the HIV epidemic, but Exposure trends and sources are increasing Substance use, Commercial sex, same sex etc. Increased ARV access- likely to drive resistance and misuse Weak monitoring structures- need evidence-backed guidance

4. Treatment failure and underlying influencers Overall, 35.9% of all patients failed treatment Failure highest among Patients receiving D4T(stavudine) regimen First-line D4T discontinued elsewhere but still widely used in Kenya 33.3% of the patients developed resistance to major drugs in use Single viral load test is efficient for treatment failure definition

5. Patients active in peer support programs had good adherence Patient with good adherence had lower viral load Peer support improves adherence & treatment outcome * ** Adherence Peer Support * ** Viral load

6. HIV as a collection of sub-epidemics of many virus strains Observed increased diversity of HIV in the drug-target genes Identified HIV-1 subtype B, only common in Europe & the Americas Multiple strains complicate disease & treatment outcomes SUBTYPE/Strain % HIV diversity within in Envelope (vaccine target)Pol (drug target) A79 67 B 0 5 C014 D010 Recombinants215

7. Increased burden of infection among substance users. 66.2% injectors and 33.8% non-injectors HIV-1 prevalence; 87.5% among injectors. Hepatitis C prevalence; injectors (16.3%) & non-injectors (4.3%)

8. ①Implement point-of-care viral load testing to monitor failure ②Implement patient-focused adherence support programs Strengthen patient-physician and patient-patient relationships ③Regularize drug toxicity testing- D4T regimen phase-out per WHO ④Institutionalize drug resistance testing (reference testing centers) ⑤Capacity building- train and impart relevant skills on testing Policy decision-points:

9. 6). Public health approach to alleviate behavioral risks Substance replacement therapy; treatment-as-a-prevention Pre-exposure prophylaxis; Test-and-treat’; self-reporting support 7). Ministry of Health to partner with research groups to Support research activities that will enhance informed policy decisions Actively monitor disease epidemiology and genetics Policy decision-points-cont…

10. Summary HIV treatment access has improved- Monitoring needs scaling Patient Participation in adherence programs useful Drug/substance abuse compromising gains Policy decisions to intersect with Research evidence Other outcomes: Graduate & undergraduate trainings, publications, Conferences

11. Acknowledgement Centre for Research in Therapeutic Sciences (CREATES) Consortium for National Health Research (CNHR) for funding