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Hiv and aids, protecting children and adolescents from hiv and aids and providing care.

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The number of children living with HIV in Kenya fell from 180,000 in 2010 to 111,500 in 2020, partly due to improved access to services, including for more pregnant women. However, infection rates among young people (15-24) remain concerning. In 2020, they accounted for 35 per cent of new infections, with two thirds of cases among young women. In Homa Bay, one of the worst-affected counties, gender inequality, difficulties in accessing services and poverty are fueling high rates of unintended pregnancies and HIV.

UNICEF's response

UNICEF supports the Government of Kenya’s national and sub-national HIV response, targeting the first and second decades of a child’s life.  This covers the elimination of mother-to-child transmission of HIV and syphilis, as well as paediatric HIV treatment and care, and adolescent HIV prevention, care and treatment. UNICEF works with other UN agencies and partners to ensure that life-saving HIV prevention, testing, treatment and care interventions are widely available and accessible to infants, children, adolescents and their parents. Integrated approaches are key to the delivery of these interventions. UNICEF works closely with civil society to engage adolescents and young people and amplify their voices on issues that affect them. We advocate for better services and adolescent-centred programming and promote behaviour change, including encouraging more young people to seek health services. We use digital and other platforms to improve adolescents' sexual and reproductive health knowledge. We involve young people in decision-making, including as advisory members and health managers. These young people empower their own peers to become more involved in issues concerning their health.  

COVID-19 response

UNICEF is supporting Ministry of Health guidance on ensuring the continuity of HIV services for children and adolescents. We are assisting county governments to provide information on continuity of HIV services for children and adolescents, including via mentor mothers, community health volunteers and Youth Advisory Councils. We also procured personal protective equipment (PPEs) for frontline health care workers who provide HIV testing services.

HIV and AIDS in numbers

Medicine

The number of children living with HIV fell from 180,000 in 2010 to 111,500 in 2020.

HIV & AIDS

In Homa Bay, young people aged 15-24 contribute 13% of the total number of HIV infections.

Children and adults

In 2020, UNICEF supported HIV counselling services for 83,000 children and youth.

Innovation

With UNICEF’s support, 3.2 million young social media users were reached with messages on sexual and reproductive health, in 2020.

Research and Reports

Unintended pregnancies and HIV among adolescents and young people Situation Analysis of Children and Women in Kenya, 2017

  • Understanding the HIV epidemic

At a glance: HIV in Kenya

A PrEP and voluntary medical male circumcision leader

Key statistics: 2021

  • 1.4 million people with HIV
  • 4% adult HIV prevalence
  • 35,000 new HIV infections
  • 22,000 AIDS-related deaths
  • 78% people on antiretroviral treatment

Progress towards targets

The current targets for HIV testing and treatment are called the 95-95-95 targets and must be reached by 2025 in order to end AIDS by 2030.

In 2021 in Kenya:

Kenya 95-95-95 targets 2023

Did you know?

About 78% of people with HIV (whether they know their status or not) are on treatment in Kenya.

Preventing HIV in Kenya focuses on:

  • condom provision
  • comprehensive sexuality education
  • PrEP (oral PrEP is available; a PrEP vaginal ring and injection are being trialled)
  • gender-based violence prevention
  • a range of prevention services for young people , particularly adolescent girls and young women
  • voluntary medical male circumcision
  • harm reduction for people who use drugs
  • prevention of mother-to-child transmission
  • integrated HIV and SRHR services, including testing and treatment for sexually transmitted infections
  • linked to HIV testing services, including partner testing.

Keeping girls in school to transition to and complete secondary education significantly reduces their vulnerability to HIV, as it helps increase girls’ control over their sexual and reproductive health and rights. Kenya’s current AIDS strategy promotes interventions that keep girls in school.

Testing for HIV is: 

  • possible via self-testing kits, which are available from vending machines in some areas
  • being expanded in the community as opposed to just at health clinics
  • being integrated into other service centres, such as contraception, vaccination, and TB clinics.

Knowledge of one’s own HIV status is lower among men and boys (88%) than among women and girls (94%).

Treatment for HIV is: 

  • initiated as soon as someone tests positive for HIV
  • seeing reduced numbers of people staying on their treatment
  • holistic, focusing on early diagnosis, mental health and psychosocial interventions.

Between 2004 and 2019, the scale up of ART treatment has averted over 733,600 AIDS-related deaths in Kenya.

Local context

Kenya’s HIV epidemic affects everyone, but men who have sex with men, women, sex workers and people who inject drugs are more likely to get HIV. Young women and girls are disproportionately affected by poverty, violence and injustice that make them vulnerable to HIV. HIV prevalence among young women is almost twice that of young men – 2.1% versus 1.2%.

HIV-related stigma remains a huge issue. The People Living With HIV Stigma Index (2021) found that 62% of people delayed taking an HIV test because they were worried about people’s reaction if they tested positive, and 47% of people with HIV who stopped or interrupted treatment did so because they were scared of people finding out they had HIV.

Kenya’s legal environment helps to drive stigma and discrimination against some groups. Homosexuality is illegal, as is drug use. Sex work is not technically criminalised but it is illegal to live off the proceeds of sex work, and other laws are also used against sex workers. Abortion is legal but only in limited circumstances on health grounds.

It is estimated that at least two thirds of couples with HIV are discordant, meaning one of the partners has HIV and one doesn’t.

Kenya was one of the first countries in sub-Saharan Africa to approve the use of oral PrEP and is one of just three countries that managed to increase access to PrEP throughout the COVID-19 pandemic.

Kenya also leads the way in providing voluntary medical male circumcision . It is the only priority country to have reached the target of 90% of men and boys obtaining the procedure.

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  • Last updated: 31 March 2023
  • Last full review: 23 September 2022
  • Next full review: 01 March 2025
  • Case Report
  • Open access
  • Published: 24 February 2024

Understanding mother-to-child transmission of HIV among mothers engaged in HIV care in Kenya: a case report

  • Emily L. Tuthill 1 ,
  • Belinda C. Odhiambo 2 &
  • Ann E. Maltby 1  

International Breastfeeding Journal volume  19 , Article number:  14 ( 2024 ) Cite this article

Metrics details

Mother-to-child transmission of HIV, which may occur in utero, during birth, or through breastmilk, is now largely preventable with the advancement of HIV testing and treatment for women and their infants. Globally, great progress has been recorded over the years, with a 58% decline in new infections in children from 2010 to 2022. Currently, Kenya is among the countries with the highest rates of mother-to-child transmission of HIV despite consistent efforts to promote prevention of mother to child transmission strategies.

This case report presents the experiences of a woman, engaged in HIV care in Kenya, whose baby contracted HIV. The data used to describe this case come from surveys, provider notes, health records, observational notes, notes from phone call consultations, and one in-depth interview. All data sources were carefully reviewed, compared and complied to describe the timeline of events and context of the participant’s experience.

We found multiple factors which may have contributed to this case of mother-to-child transmission of HIV. Antenatal care was initiated late in pregnancy (during the third trimester), and as a result, HIV diagnosis and treatment also occurred late in pregnancy. In addition, a lack of coordination between the clinic providing antenatal care and HIV treatment, and the hospital providing labor and delivery services led to breastfeeding initiation prior to the administration of infant HIV prophylaxis medications. Finally, poor maternal adherence to HIV medications went undetected and unaddressed until it was revealed by routine viral load monitoring three months after initiating HIV treatment (more than two months postpartum).

Conclusions

Our case report shows the continued need for more intensive and integrated care for mothers living with HIV and their infants including support for pregnant women newly diagnosed with HIV, coordination of perinatal and HIV care, provisions for routine monitoring of HIV medication adherence, intensive follow-up care including point of care testing for HIV exposed infants and in person breastfeeding support. Our case report contributes an important perspective especially in light of the current UNAIDS Global AIDS Strategy which recently inspired the Global Alliance to end AIDS in Children.

In 2022, there were around 1.2 million pregnant women and girls living with HIV [ 1 ]. Without any treatment, 15 to 30% of HIV exposed infants become infected during pregnancy, labor, or delivery with an additional 5–15% contracting HIV during breastfeeding [ 2 ]. However, when mothers’ viral loads are suppressed by medications during the breastfeeding period, the rate of mother to child transmission of HIV (MTCT) may be less than 2% [ 3 ]. Since 2011, international efforts have made great progress towards reducing MTCT through increased access to preventative services and antiretroviral therapy (ART) [ 4 ]. As a result, there has been a 58% decline in new infections in children from 2010 to 2022 [ 5 ]. Yet, in 2022, there were 130,000 new HIV infections among children, and global progress towards the elimination of MTCT has stagnated as the proportion of pregnant and breastfeeding women living with HIV who receive ART has remained at around 80% since 2015 [ 6 ]. In addition, after only slowly declining over several years, the global rate of MTCT was 11% in 2021 and 2022 [ 7 ]. UNAIDS’s Global AIDS Strategy 2021–2026 called attention to stalled progress towards ending AIDS in Children inspiring key stakeholders, including the World Health Organization, to propose a Global Alliance to end AIDS in Children through informed, renewed efforts [ 4 , 8 ]. In February of 2023, 12 African countries, motivated by the Alliance, created and signed the Dar es Salaam Declaration committing to a set of actions to end AIDS in Children [ 9 ].

Kenya, a country where 890,000 women are living with HIV, was one of the countries that signed the Dar es Salaam Declaration thereby committing to provide treatment and support for sustained engagement in care to all pregnant and breastfeeding women [ 9 , 10 ]. Thanks to previous efforts by the Kenyan Ministry of Health and partner agencies, 91% of pregnant women living with HIV (WLWH) were already receiving ART in 2021 [ 10 , 11 ]. Yet, the rate of MTCT in Kenya remains unacceptably high at 8.9% with an estimated 5,200 new HIV infections among children (0–14) in 2021 [ 10 ]. To eliminate MTCT in Kenya, a detailed understanding of the multi-level factors contributing to MTCT in this setting is necessary, as WLWH encounter specific challenges to preventing MTCT including late initiation of antenatal care leading to delayed HIV screening, struggles with maternal adherence to ART, difficulties remaining engaged in care, and barriers to adhering to infant feeding recommendations [ 12 , 13 , 14 , 15 , 16 ]. To understand how MTCT of HIV still occurs in this setting, we present the case of a mother living with HIV whose baby tested positive for HIV at four weeks postpartum.

Information about this case was collected from 23 February 2022 to 23 August 2022 during the feasibility trial of an intervention aimed at addressing food insecurity and supporting optimal infant feeding. The trial was conducted at a sub-County Hospital in western Kenya where prevention of mother to child transmission of HIV (PMTCT) services were provided including ART and viral load testing for women, HIV testing and prophylaxis medications for infants and counseling and education related to living with HIV and the care of HIV exposed infants. Our research team who planned and carried out the feasibility trial consisted of the Primary Investigator based in the United States (ET), a Research Coordinator (BO), a Research Assistant and a Lactation Specialist based in Kenya, and a Research Coordinator based in Denmark (AM). Participants in the intervention received personalized breastfeeding support from the Lactation Specialist until three months postpartum. Data compiled to form this case report include clinical notes from the Lactation Specialist, observation notes from the supportive sessions, phone call consultations documented by the on-site Research Coordinator, questionnaire data collected through electronic surveys, communications with healthcare providers, health records and an in-depth exit interview with the participant at approximately six months postpartum.

Case presentation

Susan (a pseudonym) was a shy, 32-year-old, unemployed, mother of two with a primary school education. She lived in informal housing in an urban area with her husband and was having a planned pregnancy. We met Susan at her 2nd antenatal care visit where she reported she was 29 weeks pregnant (estimated based on her last menstrual period). Susan had been diagnosed with HIV and started on ART at her first antenatal visit, approximately six weeks prior to our meeting. She reported that she had disclosed her new diagnosis to her husband who she believed was HIV negative. When surveyed about her adherence to ART during this initial visit, Susan reported perfect adherence. Since the first viral load test for people newly diagnosed with HIV in this setting is done three months after the initiation of ART, Susan was yet to have her viral load measured [ 17 ]. Susan was planning to exclusively breastfeed her baby for the first six months postpartum as recommended, but was concerned she may not produce enough milk [ 17 , 18 ].

About a week after we met Susan, she gave birth. This was just over seven weeks after being diagnosed with HIV, and after having attended only two prenatal care visits. Susan gave birth nearly two months earlier than expected. Her son weighed 2.8 kg (weight for age z-score = -1.18; see Fig.  1 for weight-for-age z-scores at each timepoint as compared to WHO standards), but showed no other signs of prematurity, indicating a possible miscalculation of her due date.

figure 1

The birth weight was collected from Susan’s infant’s medical record, the other infant weights were measured on a digital scale by our Research Coordinator at each postpartum research encounter. The weight-for-age z-scores plotted on this chart were then calculated using World Health Organization child growth standards [ 19 ]

Susan delivered a baby boy via normal vaginal delivery at a hospital 20 min (via motorcycle) from her home where skilled providers were present. This was a different facility from the PMTCT clinic where she had been receiving antenatal and HIV care. At the time of delivery, Susan did not have HIV prophylaxis medications for her baby (these are usually given to women at the PMTCT clinic about a month before their due date), nor did hospital staff provide Susan’s newborn with HIV prophylaxis medications. In fact, it was unclear (based on Susan’s description) whether or not the providers who cared for her during labor, delivery and immediately postpartum knew she had been recently diagnosed with HIV. Susan reported she and her baby experienced no complications. She initiated breastfeeding in the hospital, and was discharged home with her son after one day.

Four days after delivery, Susan met with the Lactation Specialist who noticed immediately that she was having challenges with breastfeeding (see Table  1 for an overview of the lactation support provided). Breastfeeding challenges aside, it was very concerning at this time to discover that Susan had not yet received her baby’s HIV prophylaxis. After meeting with the Lactation Specialist, Susan attended her regularly scheduled appointment at the PMTCT clinic where she ultimately received HIV prophylaxis medication for her baby.

At two weeks postpartum, Susan met with the Lactation Specialist again (see Table  1 ). Susan’s baby was looking sick, weak and weighing 200 g less than his birth weight (see Fig.  1 ). The Lactation Specialist was worried that the baby could have an infection, and the routine follow up appointment for Susan’s baby was not until six weeks postpartum. Thus, the Lactation Specialist arranged for Susan to be seen by the PMTCT clinicians immediately. After visiting the PMTCT clinic that same day, Susan reported she had been given Septrin (an antibiotic combination of trimethoprim and sulfamethoxazole) and Piriton (chlorphenamine, an antihistamine) to administer to her baby.

At four weeks postpartum, Susan’s baby still appeared unwell and thin, and now had oral thrush. He was not breastfeeding well, and his weight was still 100 g below his birth weight (see Fig.  1 ). Concerned about the health of Susan’s baby, the Lactation Specialist reached out to the PMTCT clinic again, this time to facilitate an early PCR HIV test for Susan’s baby (routine testing for HIV exposed infants would otherwise not occur until six weeks postpartum in this setting) [ 17 ]. Susan’s blood sample was also collected for viral load testing at this time as it had now been nearly three months since she initiated ART.

At six weeks postpartum, the Lactation Specialist assessed that Susan’s baby was looking and feeding better than in the previous visits with a weight gain of 400 g over the previous two weeks (see Fig.  1 ). At this time, Susan had not yet received the results of her viral load test or her baby’s HIV test. When surveyed about her adherence to ART, Susan reported not taking ART for an entire week of the preceding month when she travelled to her rural home and left her medications behind.

After Susan’s visit at six weeks postpartum, we were unable to get in touch with her by phone until nine weeks postpartum. At that time, we asked Susan to report to the PMTCT clinic team to receive newly available test results — Susan’s viral load was high at 1.7 million copies, and her baby’s PCR test was positive for HIV. The PMTCT clinic providers then met with Susan to counsel her and initiate HIV treatment (ART) for her son. The clinic providers suspected that Susan’s viral load was high due to poor adherence. They feared she had not disclosed her new diagnosis of HIV to her partner and had therefore not been taking her medications as directed. To address this, the clinic staff invited Susan to bring her partner to be tested at the clinic where they would provide counseling and support for disclosure and adherence. Susan’s partner eventually tested HIV negative, and expressed willingness to support Susan with her and their son’s adherence. Subsequently, Susan admitted to the clinic staff that she had been throwing away her ART ever since she had tested HIV positive during pregnancy.

At three months postpartum, Susan had her final visit with the Lactation Specialist. Her baby was now 1.07 kg more than his birth weight (see Fig.  1 ), and was looking well besides having persistent oral thrush. Susan reported she was now taking her HIV medication well.

During follow-up calls made to check on Susan and her baby at four months and five months postpartum, Susan reported that she and her baby were doing well. When she came back for her six-month appointment and exit interview, Susan and her baby looked well, she was in a good mood, laughing at times and her baby had grown considerably, now weighing 6.1 kg (see Fig.  1 ). Susan reported she was grateful for the sessions with the Lactation Specialist, which according to her, had really helped her bond with her baby, improve her milk supply, and remain engaged in HIV care. Referring to the supportive sessions she noted, “I was able to care for my baby according to the information I was given, and my baby improved. He is not the way he was, I fulfilled what I was taught here.” Susan’s routine viral load test measured at around this same time had markedly improved, though was still detectable at 102 copies/ml. She reported no ongoing challenges with adherence.

This case report outlines the circumstances surrounding one instance of MTCT which occurred in Kenya in 2022. Susan’s case provides an in-depth reporting of how MTCT is still happening, and what is needed to optimize care for WLWH and their HIV exposed infants. Late engagement in antenatal/HIV care, difficulty accepting and disclosing a new diagnosis of HIV, unrecognized non-adherence, fragmented care (e.g., giving birth at a separate facility than PMTCT clinic), and delays in HIV and viral load testing may have contributed to this case of MTCT. In contrast, sustained engagement in care, and intensive postpartum monitoring and support provided by a professional Lactation Specialist, PMTCT clinic providers, and eventually Susan’s partner may have been key to optimizing health and wellbeing for Susan and her son despite MTCT having occurred.

In 2022, more than half of new HIV infections among children occurred during pregnancy when mothers did not receive ART, stopped taking ART, or were newly infected with HIV [ 7 ]. Given Susan was more than halfway through her pregnancy when she presented for antenatal care and discovered she was living with HIV, it is possible that HIV transmission occurred during pregnancy. Women in sub-Saharan and East African countries commonly delay engagement in antenatal care which has been related to varied factors including lower maternal education, uncertainties about pregnancy status, low household income and increased birth order [ 20 , 21 ]. In Kenya, approximately 82% of women deliver their babies in a health facility and 89% are attended to by a skilled provider, yet, only around 66% of women attend the recommended four or more antenatal care visits [ 22 ]. These statistics reflect Susan’s experience as this was her third pregnancy, and despite being a planned pregnancy, timely prenatal care was missing from her plan. HIV testing is a critical component of antenatal care in this setting, and in such high prevalence areas, regular testing, regardless of pregnancy status, should also be widely promoted. In Susan’s case, HIV testing prior to or earlier in her pregnancy could have led to more timely HIV treatment and a reduced risk for MTCT.

Detecting HIV is a first step to preventing further transmission. However, receiving a new diagnosis of HIV is a life altering event, and accepting the diagnosis, disclosing it to partners and family, and committing to lifelong treatment is emotionally and sometimes practically speaking, difficult. Denial and stigma often impede optimal adherence immediately after diagnosis. Indeed, several previous studies indicate that women newly diagnosed with HIV during pregnancy struggle with adherence and are less likely to remain engaged in care and sustain viral suppression [ 15 , 23 , 24 ]. Disclosing a new diagnosis of HIV can be extremely difficult, especially in cases where the partner’s status is unknown or HIV negative. Fears of stigma, being blamed, punished or being abandoned lead some women to withhold information about their HIV status from their partner and this directly impacts their medication adherence and engagement in care [ 13 , 16 , 25 , 26 , 27 ]. In Kenya, non-disclosure of HIV status to male partners has been associated with an increased risk for MTCT [ 28 ]. Unfortunately, despite frequent interactions with providers, Susan’s struggles to reveal her HIV diagnosis to her partner and adhere to ART were not recognized until the results of her viral load test came back at around nine weeks postpartum. During our first encounter with Susan, she reported perfect adherence to ART—despite later admitting to PMTCT clinic staff she had been throwing away her medications. Indeed, self-report can be an unreliable way to assess adherence [ 29 ]. Susan’s experience underscores the need for more intensive support for perinatal women newly diagnosed with HIV including support for disclosure to partners and more frequent objective monitoring of adherence/viral suppression through viral load testing. Other recent publications have also pointed to the need for increased viral load monitoring among pregnant and breastfeeding WLWH [ 30 , 31 ].

This case of MTCT may have also occurred during labor and delivery. Kenya’s 2022 HIV prevention and treatment guidelines include ways to reduce the risk of HIV transmission during labor and birth such as minimizing vaginal examinations, using aseptic delivery techniques and avoiding artificial rupture of membranes [ 17 ]. Providers may consider these guidelines for WLWH, and HIV status is normally documented in the Mother and Child Health Handbook that mothers in Kenya typically bring to any hospital visit up to five years postpartum [ 32 ]. Yet, there is not always time for providers to review the handbook, and a lack of privacy in the maternity wards (where mothers often share beds) can leave women reluctant to discuss their HIV status with providers—this may have been the case for Susan. To complicate matters, Susan’s high viral load was yet to be discovered at the time of delivery, and neither infant PCR nor maternal viral load testing are routinely carried out at the time of birth in this setting [ 17 ]. Overall, it was not clear if any special considerations were made in managing Susan’s labor and delivery. However, improved communication with providers could have led to actions to reduce the chance of MTCT during labor and delivery.

Immediately after delivery, all women are encouraged to breastfeed their babies [ 18 ]. For WLWH, this should be after administering the first dose of HIV prophylaxis medication to their newborns [ 17 ]. Susan’s baby, who was seemingly healthy at birth, was exposed to HIV in breastmilk immediately postpartum without the protection of prophylaxis medications. In similar settings, infants who did not receive HIV prophylaxis medications were found to be at a higher risk of MTCT during breastfeeding [ 33 , 34 ]. Thus, the failure to coordinate the provision of HIV prophylaxis medications to Susan’s son immediately after birth could have also been a factor in this case of MTCT.

Early testing and optimized treatment for infants exposed to HIV is part of the first pillar of the Global Alliance to end AIDS in Children. Indeed, the Lactation Specialist’s observations and communications with clinic providers which led to an early HIV test was an important factor for Susan’s son [ 4 ]. Yet, despite being tested at four weeks postpartum (compared to the routine testing at six weeks), it was not until Susan’s baby was about nine weeks old that she received the test results and her son was given ART. This type of delay in receiving and relaying test results is not uncommon. In fact, during this period, a shortage in laboratory reagents delayed infant PCR tests for most infants. HIV tests normally drawn at six weeks postpartum were not drawn until 8–10 weeks postpartum. Such a delay may have been detrimental to Susan’s son who could have benefited from testing and treatment even earlier. According to Kenya’s most recent HIV prevention and treatment guidelines (2022), infants at high risk of HIV acquisition (such as those born to WLWH whose viral load is unknown or who have been on ART for less than 12 weeks), should be considered for HIV testing immediately after birth. This guideline, which has yet to be fully implemented, would have been applicable in the case of Susan and her son. Moreover, the Lactation Specialist’s first referral to PMTCT clinic providers at just two weeks postpartum might have also prompted earlier testing and treatment given Susan’s diagnosis late in pregnancy and her baby’s symptoms. In addition to earlier HIV testing, using point of care testing with faster turnaround times has been shown to significantly reduce the time it takes to initiate ART for newly diagnosed infants [ 35 ].

HIV exposed infants have worse outcomes than infants born to women without the virus [ 36 ]. Therefore, optimal nutrition is of paramount importance for HIV exposed infants. However, women in this setting face many challenges adhering to infant feeding guidelines including food and financial insecurity, perceived breastmilk insufficiency and contrary cultural norms [ 18 , 37 , 38 , 39 , 40 ]. Susan’s meetings with a Lactation Specialist early postpartum may have been an important factor not only through initiating early HIV testing but also by supporting Susan to sustain her exclusive breastfeeding practice. That Susan was able to maintain exclusive breastfeeding, was a protective factor for her son, as providing breastmilk only during the first six months is associated with reduced infant morbidity and mortality [ 41 , 42 ].

This case sheds light on ways MTCT may still occur even when mothers are engaged in care. Yet, the rate of MTCT among women engaged in care is low, with one study in Kenya showing a transmission rate of just 2.5% among WLWH engaged in care at four Kenyan hospitals in 2016 [ 11 ]. Given most MTCT continues to occur among women not engaged in HIV care, more action is needed to understand and eliminate barriers to HIV testing and treatment for women and girls—particularly in sub-Saharan Africa where girls and young women 15–24 years old accounted for more than 77% of all new infections among this age group in 2022 [ 5 , 7 ].

Conclusions/ recommendations

We saw in this case report of MTCT that there were multiple points along the continuum of care that may have contributed to Susan’s infant contracting HIV. The perinatal period constitutes a major transition for all women and those living with and especially newly diagnosed with HIV are juggling additional challenges that require comprehensive, ongoing and personalized support. Early initiation/attendance of antenatal care clinic visits for timely HIV diagnosis and treatment, monitoring of adherence to ART through frequent and as needed viral load monitoring, support for disclosure to partners especially for discordant couples, coordination of perinatal and HIV care, early infant point of care testing and finally support for optimal infant feeding is necessary to strengthen efforts towards the elimination of MTCT and meet global commitments to end AIDS in children.

Availability of data and materials

Data on which this manuscript are based is not publicly available due to the need to protect privacy.

Abbreviations

Human immunodeficiency Virus

Mother-to-child transmission of HIV

Polymerase Chain Reaction

Prevention of mother-to-child transmission of HIV

United Nations Children’s Fund

Women/ A Woman living with HIV

UNAIDS. HIV estimates with uncertainty bounds 1990-present. 2023. https://www.unaids.org/en/resources/documents/2023/HIV_estimates_with_uncertainty_bounds_1990-present . Accessed 31 Aug 2023.

Global guidance on criteria and processes for validation 2021 elimination of mother-to-child transmission of HIV, syphilis and hepatitis B virus World Health Organization Geneva

Zijenah LS, Bandason T, Bara W, Chipiti MM, Katzenstein DA. Mother-to-child transmission of HIV-1 and infant mortality in the first six months of life, in the era of Option B Plus combination antiretroviral therapy. Int J Infect Dis. 2021;109:92–8. https://doi.org/10.1016/j.ijid.2021.06.036 .

Article   CAS   PubMed   Google Scholar  

World Health Organization; UNAIDS; UNICEF. The global alliance to end AIDS in children. 2022. https://www.unaids.org/en/topic/alliance-children . Accessed 18 Oct 2023.

UNAIDS. UNAIDS fact sheet 2023. 2023. https://www.unaids.org/sites/default/files/media_asset/UNAIDS_FactSheet_en.pdf . Accessed 18 Oct 2023.

The path that ends AIDS: 2023 UNAIDS global AIDS update 2023. Geneva: Joint United Nations Programme on HIV/AIDS; 2023. Report No.: Licence: CC BY-NC-SA 3.0 IGO.

UNICEF. Elimination of mother-to-child transmission. 2023. https://data.unicef.org/topic/hivaids/emtct/#:~:text=This%20notion%20is%20highlighted%20by,11%20per%20cent%20in%202022 . Accessed October 10, 2023.

Global AIDS strategy 2021–2026. End inequalities. End AIDS. Geneva: UNAIDS; 2021.

UNAIDS. The Dar es Salaam declaration for action to end AIDS in children. 2023. https://www.unaids.org/en/topic/alliance-children/dar-es-salaam-declaration . Accessed 6 Oct 2023.

Joint United Nations Program on HIV/AIDS. UNAIDS data 2022. 2022. https://www.unaids.org/en/resources/documents/2023/2022_unaids_data . Accessed 18 Oct 2023.

Pricilla RA, Brown M, Wexler C, Maloba M, Gautney BJ, Finocchario-Kessler S. Progress toward eliminating mother to child transmission of HIV in Kenya: review of treatment guidelines uptake and pediatric transmission between 2013 and 2016-a follow up. Matern Child Health J. 2018;22(12):1685–92. https://doi.org/10.1007/s10995-018-2612-0 .

Article   PubMed   PubMed Central   Google Scholar  

Tuthill EL, Maltby AE, Odhiambo BC, Akama E, Pellowski JA, Cohen CR, et al. “I found out I was pregnant, and I started feeling stressed”: a longitudinal qualitative perspective of mental health experiences among perinatal women living with HIV. AIDS Behav. 2021;25(12):4154–68. https://doi.org/10.1007/s10461-021-03283-z .

Omonaiye O, Kusljic S, Nicholson P, Manias E. Medication adherence in pregnant women with human immunodeficiency virus receiving antiretroviral therapy in sub-Saharan Africa: a systematic review. BMC Public Health. 2018;18(1):805. https://doi.org/10.1186/s12889-018-5651-y .

Alhassan Y, Twimukye A, Malaba T, Myer L, Waitt C, Lamorde M, et al. “I fear my partner will abandon me”: the intersection of late initiation of antenatal care in pregnancy and poor ART adherence among women living with HIV in South Africa and Uganda. BMC Pregnancy Childbirth. 2022;22:566. https://doi.org/10.1186/s12884-022-04896-5 .

Akama E, Nimz A, Blat C, Moghadassi M, Oyaro P, Maloba M, et al. Retention and viral suppression of newly diagnosed and known HIV positive pregnant women on Option B+ in Western Kenya. AIDS Care. 2019;31(3):333–9. https://doi.org/10.1080/09540121.2018.1524565 .

Article   PubMed   Google Scholar  

Yah CS, Tambo E. Why is mother to child transmission (MTCT) of HIV a continual threat to new-borns in sub-Saharan Africa (SSA). J Infect Public Health. 2019;12(2):213–23. https://doi.org/10.1016/j.jiph.2018.10.008 .

Kenya HIV prevention and treatment guidelines 2022. Nairobi: Ministry of Health, National AIDS & STI Control Program; 2022.

Guideline: updates on HIV and infant feeding: the duration of breastfeeding, and support from health services to improve feeding practices among mothers living with HIV. Geneva: World Health Organization and United Nations Children’s Fund; 2016.

World Health Organization. Tools and toolkits/ child growth standards/ standards/ weight for age. https://www.who.int/tools/child-growth-standards/standards/weight-for-age . Accessed 11 Jan 2024.

Mlandu C, Matsena-Zingoni Z, Musenge E. Trends and determinants of late antenatal care initiation in three East African countries, 2007–2016: A population based cross-sectional analysis. PLOS Glob Public Health. 2022;2(8): e0000534. https://doi.org/10.1371/journal.pgph.0000534 .

Pell C, Menaca A, Were F, Afrah NA, Chatio S, Manda-Taylor L, et al. Factors affecting antenatal care attendance: results from qualitative studies in Ghana, Kenya and Malawi. PLoS ONE. 2013;8(1): e53747. https://doi.org/10.1371/journal.pone.0053747 .

Article   ADS   CAS   PubMed   PubMed Central   Google Scholar  

Kenya demographic and health survey 2022. Key indicators report. Nairobi, Kenya, and Rockville, Maryland, USA: KNBS and ICF; 2023.

Yotebieng M, Mpody C, Ravelomanana NL, Tabala M, Malongo F, Kawende B, et al. HIV viral suppression among pregnant and breastfeeding women in routine care in the Kinshasa province: a baseline evaluation of participants in CQI-PMTCT study. J Int AIDS Soc. 2019;22(9): e25376. https://doi.org/10.1002/jia2.25376 .

Myer L, Dunning L, Lesosky M, Hsiao NY, Phillips T, Petro G, et al. Frequency of viremic episodes in HIV-Infected women initiating antiretroviral therapy during pregnancy: a cohort study. Clin Infect Dis. 2017;64(4):422–7. https://doi.org/10.1093/cid/ciw792 .

Rujumba J, Neema S, Byamugisha R, Tylleskar T, Tumwine JK, Heggenhougen HK. “Telling my husband I have HIV is too heavy to come out of my mouth”: pregnant women’s disclosure experiences and support needs following antenatal HIV testing in eastern Uganda. J Int AIDS Soc. 2012;15(2):17429. https://doi.org/10.7448/IAS.15.2.17429 .

Onono M, Odwar T, Abuogi L, Owuor K, Helova A, Bukusi E, et al. Effects of depression, stigma and intimate partner violence on postpartum women’s adherence and engagement in HIV care in Kenya. AIDS Behav. 2020;24(6):1807–15. https://doi.org/10.1007/s10461-019-02750-y .

hIarlaithe MO, Grede N, de Pee S, Bloem M. Economic and social factors are some of the most common barriers preventing women from accessing maternal and newborn child health (MNCH) and prevention of mother-to-child transmission (PMTCT) services: a literature review. AIDS Behav. 2014;18(Suppl 5):S516-30. https://doi.org/10.1007/s10461-014-0756-5 .

McGrath CJ, Singa B, Langat A, Kinuthia J, Ronen K, Omolo D, et al. Non-disclosure to male partners and incomplete PMTCT regimens associated with higher risk of mother-to-child HIV transmission: a national survey in Kenya. AIDS Care. 2018;30(6):765–73. https://doi.org/10.1080/09540121.2017.1400642 .

Alcaide ML, Ramlagan S, Rodriguez VJ, Cook R, Peltzer K, Weiss SM, et al. Self-report and dry blood spot measurement of antiretroviral medications as markers of adherence in pregnant women in rural South Africa. AIDS Behav. 2017;21(7):2135–40. https://doi.org/10.1007/s10461-017-1760-3 .

Myer L, Essajee S, Broyles LN, Watts DH, Lesosky M, El-Sadr WM, et al. Pregnant and breastfeeding women: A priority population for HIV viral load monitoring. PLoS Med. 2017;14(8): e1002375. https://doi.org/10.1371/journal.pmed.1002375 .

Vrazo A, Sullivan D, Phelps B. Eliminating mother-to-child transmission of HIV by 2030: 5 strategies to ensure continued progress. Global Health Science and Pratice. 2018;6(2):249–56.

Article   Google Scholar  

Mother & child health handbook Republic of Kenya Minitsry of Health; 2020. Report No.: MOH216.

Koye DN, Zeleke BM. Mother-to-child transmission of HIV and its predictors among HIV-exposed infants at a PMTCT clinic in northwest Ethiopia. BMC Public Health. 2013;13:398 http://www.biomedcentral.com/1471-2458/13/398 .

Hurst SA, Appelgren KE, Kourtis AP. Prevention of mother-to-child transmission of HIV type 1: the role of neonatal and infant prophylaxis. Expert Rev Anti Infect Ther. 2015;13(2):169–81. https://doi.org/10.1586/14787210.2015.999667 .

Article   CAS   PubMed   PubMed Central   Google Scholar  

Sacks E, Cohn J, Ochuka B, Mafaune H, Chadambuka A, Odhiambo C, et al. Impact of routine point-of-care versus laboratory testing for early infant diagnosis of HIV: results from a multicountry stepped-wedge cluster-randomized controlled trial. J Acquir Immune Defic Syndr. 2020;84(Suppl 1):5–11.

Modi S, Broyles LN, Montandon M, Itoh M, Ochanda B, Langat A, et al. Beyond early infant diagnosis: changing the approach to HIV-exposed infants. J Acquir Immune Defic Syndr. 2018;78(Suppl 2):107–14. https://doi.org/10.1097/QAI.0000000000001736 .

Tuthill EL, Maltby AE, Odhiambo BC, Akama E, Dawson-Rose C, Cohen CR, et al. Financial and food insecurity are primary challenges to breastfeeding for women living with HIV in western Kenya: a longitudinal qualitative investigation. AIDS Behav. 2023;27(10):3258–71. https://doi.org/10.1007/s10461-023-04046-8 .

Operto E. Knowledge, attitudes, and practices regarding exclusive breastfeeding among HIV-positive mothers in Uganda: A qualitative study. Int J Health Plann Manage. 2020;35(4):888–96. https://doi.org/10.1002/hpm.2966 .

Mbagaya GM. Child feeding practices in a rural Western Kenya community. Afr J Prim Health Care Fam Med. 2009;1:1. https://doi.org/10.4102/phcfm.v1i1.15 .

Kavle JA, LaCroix E, Dau H, Engmann C. Addressing barriers to exclusive breast-feeding in low- and middle-income countries: a systematic review and programmatic implications. Public Health Nutr. 2017;20(17):3120–34. https://doi.org/10.1017/S1368980017002531 .

Victora CGP, Bahl RMD, Barros AJDP, França GVAP, Horton SP, Krasevec JM, et al. Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effect. Lancet. 2016;387(10017):475–90. https://doi.org/10.1016/S0140-6736(15)01024-7 .

Sankar MJ, Sinha B, Chowdhury R, Bhandari N, Taneja S, Martines J, et al. Optimal breastfeeding practices and infant and child mortality: a systematic review and meta-analysis. Acta Paediatr. 2015;104(467):3–13. https://doi.org/10.1111/apa.13147 .

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Acknowledgements

We would like to thank the staff of the sub-county hospitals in Kenya for supporting our study as well as the participant who kindly shared her experience with us. We would also like to thank Kenya Medical Research Institute (KEMRI) for providing ethical oversight and the Director General KEMRI for scientific and administrative support.

ELT was supported by the National Institutes of Health under Grants K23MH116807 (ELT).

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Tuthill, E.L., Odhiambo, B.C. & Maltby, A.E. Understanding mother-to-child transmission of HIV among mothers engaged in HIV care in Kenya: a case report. Int Breastfeed J 19 , 14 (2024). https://doi.org/10.1186/s13006-024-00622-3

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case study of hiv aids in kenya

Widowhood in the era of HIV/AIDS: a case study of Slaya District, Kenya

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Luo women are believed to acquire contagious cultural impurity after the death of their husbands that is perceived as dangerous to other people. To neutralise this impure state, a sexual cleansing rite is observed. In the indigenous setting, the ritual was observed by a brother-in-law or cousin of the deceased husband through a guardianship institution. However, with the emergence of HIV/AIDS, many educated brothers-in-law refrain from the practice and instead hire professional cleansers as substitutes. If the deceased spouses were HIV positive, the ritual places professional cleansers at risk of infection. Thereafter, they could act as a bridge for HIV/AIDS transmission to other widows and to the general population. This paper provides insights into reasons for continuity of widowhood rites in Siaya District. Twelve focus group discussions and 20 in-depth interviews were conducted. The cultural violence against Luo widows could spread HIV/AIDS, but Christianity and condoms act as coping mechanisms.

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Active pediatric HIV case finding in Kenya and Uganda: A look at missed opportunities along the prevention of mother-to-child transmission of HIV (PMTCT) cascade

Roles Conceptualization, Data curation, Methodology, Project administration, Supervision, Visualization, Writing – original draft

* E-mail: [email protected]

Affiliation Elizabeth Glaser Pediatric AIDS Foundation, Washington, DC, United States of America

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Roles Conceptualization, Methodology, Project administration, Supervision, Writing – review & editing

Affiliation Elizabeth Glaser Pediatric AIDS Foundation, Mbarara, Uganda

Roles Data curation, Formal analysis, Methodology, Validation, Writing – review & editing

Affiliation Department of Biostatistics and Bioinformatics, Milken Institute School of Public Health, George Washington University, Washington, DC, United States of America

Roles Supervision, Writing – review & editing

Affiliation Kenya Ministry of Health, Homa Bay County, Nairobi, Kenya

Affiliation Uganda Ministry of Health, Kampala, Uganda

Roles Conceptualization, Funding acquisition, Methodology, Writing – review & editing

Affiliations Elizabeth Glaser Pediatric AIDS Foundation, Washington, DC, United States of America, Department of Biostatistics and Bioinformatics, Milken Institute School of Public Health, George Washington University, Washington, DC, United States of America

Affiliation Elizabeth Glaser Pediatric AIDS Foundation, Nairobi, Kenya

  • Michelle M. Gill, 
  • Eliab K. Natumanya, 
  • Heather J. Hoffman, 
  • Gordon Okomo, 
  • Geoffrey Taasi, 
  • Laura Guay, 
  • Rose Masaba

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  • Published: June 2, 2020
  • https://doi.org/10.1371/journal.pone.0233590
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Fig 1

Children living with HIV remain undiagnosed due to missed opportunities along the prevention of mother-to-child HIV transmission cascade. This study addresses programmatic gaps in the cascade by describing pregnancy and HIV-related services received by mothers of children newly identified as HIV-positive through active case finding.

This was a prospective observational cohort (2017–2018) of HIV-positive children <15 years of age newly diagnosed at study facilities and/or surrounding communities in Kenya and Uganda. At enrollment, caregivers were interviewed about maternal and child health and HIV history. Child medical and laboratory information was abstracted at two months post-diagnosis. Descriptive summary statistics were calculated; associations between selected factors and child age at HIV diagnosis were evaluated using generalized estimating equations.

174 HIV-positive children (median age 2.4 years) were enrolled. Among maternal caregivers, 110/132 (83.3%) attended antenatal care and 60 (45.5%) reported testing HIV-negative in antenatal care. Of 41 and 56 women known to be HIV-positive during pregnancy and breastfeeding respectively, 17 (41.5%) and 15 (26.8%) did not receive antiretroviral drugs. Despite known maternal HIV-positive status during pregnancy, 39% of these children were not diagnosed until after two years of age; children were diagnosed at younger ages in Uganda (p = 0.0074) and if mother was the caregiver (p<0.0001). The most common HIV testing points identifying children were outpatient (44.3%) and maternal/child health departments (29.9%). Nearly all children initiated antiretroviral therapy within two weeks of diagnosis.

Conclusions

Multiple missed opportunities for HIV prevention and delays in HIV testing of HIV-exposed children were identified in newly diagnosed children. Findings support critical prevention messaging and retesting of HIV-negative women during pregnancy and breastfeeding, strengthening HIV treatment initiation and follow-up systems and interventions to ensure HIV-positive women receive lifelong antiretroviral therapy throughout the cascade, and broader implementation of community case finding so children not engaged in care receive testing services.

Citation: Gill MM, Natumanya EK, Hoffman HJ, Okomo G, Taasi G, Guay L, et al. (2020) Active pediatric HIV case finding in Kenya and Uganda: A look at missed opportunities along the prevention of mother-to-child transmission of HIV (PMTCT) cascade. PLoS ONE 15(6): e0233590. https://doi.org/10.1371/journal.pone.0233590

Editor: Evelyn Byrd Quinlivan, AIDS Healthcare Foundation, UNITED STATES

Received: June 11, 2019; Accepted: May 4, 2020; Published: June 2, 2020

Copyright: © 2020 Gill et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: The dataset will be published upon acceptance of the manuscript at this site: https://dataverse.harvard.edu/dataverse/projectsoar .

Funding: This work was supported by Project SOAR (Cooperative agreement AID-OAA-A-14-00060), made possible by the generous support of the American people through the United States President's Emergency Plan for AIDS Relief (PEPFAR) and United States Agency for International Development (USAID). The contents of this paper are the sole responsibility of the authors and do not necessarily reflect the views of PEPFAR, USAID, or the United States Government.

Competing interests: The authors have declared that no competing interests exist.

Introduction

Accelerated progress in preventing new pediatric HIV infections and treating HIV-positive infants is imperative for decreasing the morbidity and mortality of children worldwide. Massive scale-up of prevention of mother-to-child HIV transmission (PMTCT) services, HIV testing services (HTS), antiretroviral therapy (ART), and HIV prevention services have resulted in a 35% decrease in new pediatric infections between 2010 and 2017 [ 1 , 2 ]. Yet, in 2017, an estimated 180,000 children ages 0–14 years were newly infected with HIV. Of the 1.8 million children living with HIV, only 52% had access to ART [ 1 ]. Early identification of HIV infection in children followed by rapid ART initiation is critical to their survival [ 3 ]. HIV-exposed children should receive HIV DNA-PCR testing within two months of birth and be provided prompt treatment if diagnosed as HIV-infected. However, only half of HIV-exposed infants receive early infant diagnostic testing by eight weeks of age and far fewer are retested following breastfeeding cessation [ 4 ]. Intensified efforts are needed to reach UNAIDS’ “95-95-95” global targets of 95% of people living with HIV (PLHIV) identified, 95% of those infected on ART and 95% of those on ART with viral suppression by 2030, especially among children.

Mother-to-child transmission continues to account for over 90% of new pediatric infections, yet significant numbers of children remain undiagnosed. Adhering to all steps in the PMTCT cascade, which begins with all pregnant women and ends with either a final HIV-negative test result after breastfeeding cessation for HIV-exposed infants or a diagnosis of HIV infection [ 5 ], is needed to prevent vertical transmission and diagnose new infections early. These steps include testing pregnant women and their partners of unknown HIV status early in antenatal care (ANC), initiating HIV-positive women on ART, retaining women in care through delivery and postpartum, retesting HIV-negative women, encouraging recommended breastfeeding practices, and providing early infant diagnosis and final HIV antibody testing after breastfeeding. Focusing on reaching all pregnant mothers and children throughout the PMTCT cascade will decrease the number of new pediatric infections and link HIV-positive children to care and treatment.

There are numerous facility and community testing venues and testing strategies used to identify HIV-positive infants, yet barriers to pediatric HIV testing remain. Strategies include provider-initiated testing and counseling (PITC), voluntary counseling and testing (VCT) services, testing campaigns and index testing, a process in which providers elicit a list of sexual (or injectable drug-using) partners and children of index clients, the individuals first identified as HIV-positive, and offer HIV testing to those contacts [ 6 – 10 ]. Index testing in which contacts are identified and tested at home provides a promising opportunity to reach children [ 9 , 11 , 12 ]. Barriers that inhibit the success of testing strategies include the distance from testing facilities, long wait times, shortages of test kits or laboratory reagents, fear of stigma and concerns about privacy, opposition from partners and family, and loss to follow-up along the PMTCT cascade [ 6 , 13 ]. Like most health interventions, the success of HIV testing strategies is context-dependent, thus considering the challenges and characteristics of unique settings is necessary to determine the feasibility and effectiveness of different models for early identification of pediatric HIV infections.

This study aimed to describe the PMTCT services received by the mothers of children newly identified as HIV-positive in selected facilities and surrounding communities in Kenya and Uganda. An understanding of what steps in the PMTCT cascade were missed can target efforts to strengthen these services and prevent future pediatric infections. We also described children’s testing entry points and the strategies through which they were identified as HIV-positive as well as their HIV testing history and clinical profiles at diagnosis to inform approaches to pediatric case finding, including for older children who may have limited interactions with the health system.

Materials and methods

This study was conducted in Homa Bay County, Kenya and the southwest region of Uganda. Homa Bay is a county in western Kenya with high HIV prevalence in adults (20.7%), while southwest Uganda is a region of medium HIV prevalence in adults (7.9%) [ 14 , 15 ]. In Kenya and Uganda respectively, 110,000 and 95,000 children aged 0 to 14 years were estimated to live with HIV in 2017 [ 16 , 17 ].

In both countries, several strategies for identifying HIV-positive children < 15 years of age are used by Ministry of Health (MOH) programs, with support of the Elizabeth Glaser Pediatric AIDS Foundation (EGPAF). As opposed to passive case identification, active case finding requires additional targeted efforts to identify affected individuals. Active case finding strategies include testing children attending all outpatient and inpatient services and in key service delivery areas (e.g., malnutrition, tuberculosis), index testing, door-to-door testing, and community testing campaigns. Kenya provides ART for children identified as HIV-positive, with universal “Test and Start” guidelines implemented in July 2016 [ 18 ]. A “Test and Start” policy for HIV-positive children <15 years of age has been in place in Uganda since 2014 [ 19 ].

Study design, population and sampling

This was a prospective observational cohort study of HIV-positive children <15 years of age who were newly diagnosed at either a study facility or surrounding study community where HIV testing was offered and their mothers or primary caregivers. Children were enrolled at the time of HIV diagnosis with follow up for two months.

Children were enrolled from 45 selected facilities: 15 facilities in six sub-counties of Homa Bay and 30 facilities in 12 districts of southwest Uganda. Sites were purposively selected to include low- (1–9 HIV-positive children identified in six months) and high- (≥ 10 HIV-positive children identified in six months) volume facilities with a mix of sub-county hospitals, health centers, and dispensaries in Kenya and hospitals and health centers IV, III and II in Uganda. In total, there were 25 low-volume and 20 high-volume study facilities.

Health facility staff working in various clinics and departments referred caregivers of newly diagnosed potentially eligible children to study staff based at study facilities. Health workers at study facilities also conducted community outreach and were accompanied by study staff to the extent possible. In Kenya, children testing HIV-positive through community-based testing programs were referred to health facilities for confirmation of HIV status and linkage to HIV care and treatment services, where they were then screened for study eligibility. In Uganda, participants were primarily enrolled in the communities.

Prior to the initiation of study procedures, written informed consent was obtained from mothers or caregivers of newly diagnosed HIV-positive children by trained study staff. In Uganda, non-emancipated minors 8–14 years of age were asked to provide written assent following their caregivers’ consent, while in Kenya, a waiver of assent from children was approved by the Institutional Review Board (IRB).

Data collection and statistical analysis

At enrollment, caregivers were interviewed to collect caregiver and child demographics and caregiver HIV and ART status (whether or not the caregiver was the child’s mother). If the biological mother or father was the caregiver interviewed, they were also asked about mother’s history of ANC attendance and HIV testing and ARV/PMTCT drug use in ANC if HIV-positive. All caregivers were also asked about the child’s previous HIV testing and testing entry point for the current HIV test. Enrollment took place November 2017 to May 2018 in Kenya and March to October 2018 in Uganda. Study staff abstracted child medical and laboratory information from clinic registers at two months post-diagnosis, including child ART initiation date, clinical conditions, and any follow-up visits. If records were incomplete, study staff contacted the caregiver or visited the household in a few cases (Uganda only) to obtain outcome information (linked to care at another facility, defaulted from appointments, or deceased).

Descriptive summary statistics were calculated for outcome variables of interest using frequencies and percentages for categorical variables, and medians and interquartile ranges and mean and standard deviations for continuous variables. Associations between sociodemographic, clinical and facility characteristics and child age at HIV diagnosis were evaluated using unadjusted and adjusted generalized estimating equations (GEE) having a normal distribution with an identity link function and a compound symmetry working correlation structure. Analyses included both country-specific and combined country modeling. Only those variables significant at the 0.20 level in the unadjusted GEE models were considered for the adjusted GEE model. All statistical tests were two-sided and the level of statistical significance was set at 0.05.

Ethical approval

The protocol was approved by the George Washington University IRB in the United States, the African Medical Research Foundation’s Ethical and Scientific Research Committee in Kenya, and the National AIDS Research Committee in Uganda.

In total, 176 children and their caregivers were enrolled in the study; however, two children were excluded in Kenya due to ineligibility (final Kenya: 74, Uganda: 100) ( Fig 1 ).

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The overall median age of caregivers in Kenya and Uganda was 29 years (interquartile range [IQR] 24–38) ( Table 1 ). The median age of children was 2.4 years (IQR 0.9–6.2). Children were slightly older in Kenya (3.6 years) than in Uganda (2.0 years). The majority (69.5%) of caregivers were the child’s biological mother. Overall, 138 (79.3%) of the caregivers (98.3% of mothers) were HIV-positive and 86.2% of HIV-positive caregivers were on ART.

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Antenatal and postpartum care

Information on mothers’ antenatal care is presented only from biological mother and father caregivers. Information from two biological mothers is excluded from Table 2 below, as they reported not being HIV-positive, thus ruling out mother-to-child transmission (MTCT) in their children. One child in Kenya (14 years of age) was presumed to be infected through sexual transmission; another child in Uganda (8 years of age) was reportedly raped by a relative. Data from 132 biological caregivers are reported in Table 2 (Kenya: 59, Uganda: 73). In Kenya, 47 (79.7%) and in Uganda, 63 (86.3%) mothers attended ANC; two known HIV-positive women in each country did not attend ANC. In total, of the 93 mothers who had an HIV test in ANC, 60 (64.5%) initially tested HIV-negative leading to 45.5% overall who reported testing HIV-negative in ANC. Of 41 and 56 known HIV-positive women during pregnancy and breastfeeding respectively, 17 (41.5%) and 15 (26.8%) did not receive antiretroviral (ARV) drugs. Reasons included clinic not offering ARVs as part of antenatal care or during breastfeeding, defaulting from clinic, home delivery, HIV status denial, and other/unknown reasons (e.g., financial, religious). Overall 36.6% of mothers did not deliver in a facility. Of those with breastfeeding information available, mothers breastfed their children for a median 13 months (IQR 6–24) in Kenya (n = 62) and 12 months (IQR 6–18) in Uganda (n = 82), though some mothers were still breastfeeding at the time of the interview; eight caregivers in Uganda reported no breastfeeding.

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Child HIV testing

Overall, 31 (17.8%) children were previously tested for HIV ( Table 3 ). The two children infected through horizontal transmission had not received a prior HIV test. The majority of children (58.1%) had their last test at less than two years of age. In Kenya, all 17 children with a prior HIV test received an HIV-negative test result. In Uganda, eight received a negative result, three an indeterminate result, two never received the result, and one caregiver did not know the result; of the 25 children with a previous HIV- negative result, 16 were ≤ 2 years of age. The most common reasons for not testing was that testing was not offered to the child (n = 34), the caregiver did not see a reason to test the child or perceived the child to be healthy (n = 23), and that the mother did not yet know her HIV-positive status (n = 16) ( Fig 2A ). Of note, the same caregivers did not give more than one of these three common responses, except for two respondents who indicated that they did not see a reason to test the child and that the mother did not yet know her status. Other reasons cited for not testing the child were that the caregiver had not bothered or thought to do it and that the caregiver believed the child was ill for other reasons. About half of the unknown responses were from the biological mothers. The most common reason for testing the child on the day s/he was diagnosed as HIV-positive was that the child had become sick or weak ( Fig 2B ).

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A. Reasons child was not tested previously for HIV. In Uganda only, some caregivers provided multiple responses for a total of 137 responses (n = 120). B. Reasons why child was tested today for HIV In both countries, some caregivers provided multiple responses for a total of 247 responses (n = 173).

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Most enrolled HIV-positive children were identified in the outpatient department (OPD) (44.3%) and MCH/ PMTCT entry points (29.9%), followed by inpatient department (IPD) and community outreach ( Table 3 ). Trends were similar for the individual countries, except a greater proportion of HIV-positive children were identified in IPD in Uganda (11% vs. 5% in Kenya). Most of the newly diagnosed children enrolled in the study were identified through PITC.

Timing of maternal and child HIV diagnoses

Of the 41 mothers who were known or tested HIV-positive during pregnancy, 25 (61.0%) of their infants were diagnosed by age two years, while eight children (19.5%) were >2 - <5 years when diagnosed, and eight were not diagnosed until age 5–12 years, though the caregivers of seven children >2–12 years reported their child previously tested HIV-negative (Kenya only). Of 76 mothers with HIV diagnosis after delivery and with complete mother-child HIV diagnosis information, 26 (34.2%) mothers and children were diagnosed on the same day and 31 (40.8%) of their children were diagnosed as HIV-positive between one day and two months after the mother tested HIV-positive. Eight children (10.5%) were not diagnosed until 1–7 years after the mother tested HIV-positive, two of whom reportedly tested HIV-negative prior to the current test. In Kenya, an additional three children were diagnosed before maternal diagnosis of HIV.

In adjusted GEE models, children were diagnosed at younger ages if the mother/child pair was in Uganda (p = 0.0074) and if the biological mother was the caregiver (p<0.0001) ( Table 4 ). Caregiver’s educational background, caregiver’s ART status, the mother’s timing of HIV diagnosis (pregnancy versus after delivery), presence of child symptoms/opportunistic infections (OI), and the health facility location and level were not found to be statistically significantly associated with child age at HIV diagnosis in the combined country analyses. Modeling for each country individually found the caregiver relationship significantly associated (Kenya: p<0.0001, Uganda: p = 0.0040). In Uganda only, children were diagnosed at a younger age in urban compared to rural facilities (p = 0.030); higher-level facilities (e.g., hospitals) were marginally significantly associated with younger age at diagnosis (p = 0.044).

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https://doi.org/10.1371/journal.pone.0233590.t004

Child clinical outcomes and linkage to care and treatment

At the time of enrollment into HIV care and treatment, nearly half of the children (45.9%) presented with one or more clinical symptoms, though the majority of children (88.3%) were assessed as WHO stage I or II ( Table 5 ). Fewer children in Kenya than Uganda had clinical symptoms (38.9% vs. 51.0% respectively). The most common conditions were chronic upper respiratory tract infections, malnutrition, and weight loss, though the latter two were more common in Ugandan children.

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https://doi.org/10.1371/journal.pone.0233590.t005

The majority of children started ART, including the two children with likely horizontal transmission; only two children in Kenya did not initiate treatment. The mean time from HIV diagnosis to ART initiation was 2.7 days (standard deviation: 6.6) with a maximum of 35.0 days (earlier in Uganda). Overall, 122 (70.9%) initiated ART on the same day as diagnosis, more frequently in Uganda than Kenya (81.0% versus 56.9%). The most common ART regimens were abacavir/lamivudine/lopinavir-ritonavir (69, 40.1%) and abacavir/lamivudine/efavirenz (69, 40.1%); 23 children (13.5%) received nevirapine combined with abacavir/lamivudine (n = 7) or zidovudine/lamivudine (n = 16) with most nevirapine-based regimens in Uganda. Ten children (5.8%) received tenofovir/lamivudine/efavirenz.

The median number of follow-up visits in the two-month period after diagnosis was 3.0 (IQR 2.0–3.0) and 2.0 (IQR 1.0–2.0) for children in Kenya and Uganda respectively. In total, 92.0% of children (Kenya: 72, Uganda: 88) had one or more follow-up visits and were not known to be deceased or defaulted by the two-month follow-up period ( Fig 1 ); 10 of these children sought care and treatment services at a facility different from the testing facility. All five children who died were age ≤ two years; one child died in Kenya before follow-up data were collected, and all four children who died in Uganda were assessed as WHO Stage 3 and initiated ART prior to death. Nine children defaulted during follow-up (Kenya: 1, Uganda: 8).

There were multiple missed opportunities for prevention of HIV infection in newly diagnosed children living with HIV in Uganda and Kenya identified in our study, including gaps in ANC attendance, re-testing during pregnancy and breastfeeding, and initiation of maternal ARVs. Among study mothers and fathers of newly diagnosed children living with HIV in Uganda and Kenya in 2017–2018, 60 (45.5%) reported that the mother tested HIV-negative in ANC, suggesting that undetected incident HIV infection was a significant contributor to new infant infections. A significant proportion of HIV-positive mothers of newly diagnosed children did not receive ARVs during pregnancy or breastfeeding despite known HIV status. There were also gaps between maternal and child diagnoses, indicating possible delays in delivery of HIV testing services to HIV-exposed children. However, once HIV infection was diagnosed in children, there was accelerated linkage with HIV care and treatment services, with nearly all children initiated on ART within two weeks of diagnosis.

The proportion of women who attended ANC in both countries was lower compared to data from recent Demographic and Health Surveys. Eighty percent of study women in Kenya attended ANC compared to a national rate of 96% [ 20 ]. In Uganda, 86% of study women attended ANC versus a national rate of 97% [ 21 ]. In Kenya and Uganda, respectively, 38% and 35% of women delivered at home; the national rate of home deliveries in Uganda is considerably lower at 25% [ 21 ]. ANC serves as a key entry point for PMTCT services and both late pregnancy visits and the time of labor and delivery offer opportunities for retesting HIV-negative women [ 22 , 23 ].

Overall, most women attending ANC were offered HIV testing, though 11% of women in Uganda did not receive HIV testing. Among the 93 mothers who reportedly tested in ANC, nearly two-thirds tested HIV-negative. HIV retesting around the time of labor and delivery and during the postnatal period occurred more frequently in Uganda. A review of HIV service delivery in six sub-Saharan African countries, including Kenya and Uganda, revealed weaknesses with inconsistent implementation of provider-initiated HIV testing in ANC and less frequent retesting in pregnancy [ 24 ]. Barriers to retesting during pregnancy and postpartum persist at the individual, facility and health system levels [ 25 ]. Increasingly, incident infection is identified as a major contributor to new pediatric infections. The risk of HIV acquisition in pregnancy and early postpartum periods is elevated compared to non-pregnant women [ 26 ], and women with incident HIV infection had a greater risk of transmission of HIV to their infants compared to women with chronic HIV infection [ 27 – 29 ]. Implementing re-testing during pregnancy and the breastfeeding period and providing risk-reduction strategies, including pre-exposure prophylaxis to HIV-negative women at risk of HIV, are critical to the ability to achieve elimination of MTCT.

A considerable number of women with known HIV or who were newly diagnosed as HIV-positive in ANC were not initiated on ARVs during antenatal or postnatal care, largely due to ARVs not being offered by the health facility and disengagement from care. More women in Uganda were initiated on lifelong ART during breastfeeding than in Kenya; this may be due to a more established universal maternal ART (“Option B+”) program at the time of the majority of child diagnoses, which provided ART to all HIV-positive pregnant or breastfeeding women. Children in Uganda were younger (2.0 versus 3.6 years) and Option B+ was implemented earlier when compared to Kenya (2013 versus 2014) [ 30 , 31 ]. Given the critical importance of treatment and viral suppression in PMTCT and maternal health, it is not surprising that a disproportionate number of HIV-positive mothers of children newly diagnosed with HIV did not receive ARVs. Globally in 2017, 80% [61–>95%] of HIV-positive women received any ARV; in eastern and southern Africa, ARV access for pregnant women reached 93% [73–>95%] [ 1 ]. Women who do not receive ARVs are at high risk of transmitting HIV to their infants; barriers to ART initiation in the era of universal maternal ART include fear of lifelong treatment, feeling ill-prepared or too healthy to start treatment, and insufficient counseling [ 32 , 33 ]. Interventions shown to improve ART initiation and adherence include co-location of antenatal and ART services, strong linkages between services (e.g., peer escorts to treatment facilities), interventions to improve male partner involvement, electronic tracking systems, mHealth interventions, and differentiated care models to allow more intensive approaches to women newly diagnosed with HIV or those on ART with viral failure [ 24 , 34 – 36 ].

Nearly half of the children presented with one or more clinical symptoms, and more than half of the caregivers reported that their child becoming sick or weak was the impetus for testing the child. This aligns with previous research indicating higher yields of HIV-positive children at entry points where children tend to be sicker, such as IPD [ 7 , 37 , 38 ]. HIV-positive children should be identified before they are ill and initiated on treatment; however, the lack of clinical symptoms in a majority of children suggests continued gaps with case finding for older asymptomatic children.

In mothers diagnosed with HIV after delivery, 75% of their children were diagnosed with HIV within two months of maternal diagnosis, but one quarter of children were not diagnosed for several months to years following maternal diagnosis. Additionally, 39% of children of mothers with known HIV infection during pregnancy were not diagnosed until after age two years. Of those caregivers responding to why the child was not tested previously for HIV, 42.5% indicated that they were never offered testing for their children. Other studies have also documented institutional barriers to pediatric HIV testing, such as laboratory reagent stock-outs, weak tracking systems that do not follow up infants for testing and limited provider-initiated HIV testing for unknown or unreported child exposure at clinics outside of PMTCT/MCH [ 13 , 39 ].

Additionally, 14.4% of HIV-positive children had a prior test for HIV that was negative. A study in Lesotho found a 1.0% positivity rate (41/4051) among children of index clients 2–14 years of age who had been tested previously [ 11 ]. A facility-based study in Zimbabwe of 6–15 year olds found that children 12 years and older were less likely to be offered HIV testing [ 40 ]. This group also had the lowest testing acceptance rate, yet the median age of children testing HIV-positive was 11 years. Demand and supply side factors, such as low HIV risk perceptions and consenting issues (old enough to attend clinic alone but not old enough to consent to testing or to be offered testing by providers) may contribute to missed positive cases in this young adolescent age group [ 40 , 41 ]. More intensive, less traditional approaches to case finding may be required for perinatally infected but undiagnosed older children.

Community-based and index testing strategies accounted for a relatively small proportion of HIV-positive cases in our study. PITC accounted for the majority of cases primarily because children < 5 years comprised over 70% of our study population. When they presented to care in MCH/PMTCT or for under-five focused services, the children were tested because they were known to be HIV-exposed or because their mother just tested HIV-positive. Fewer children were identified through index testing procedures, which included active solicitation of contacts, tracing and testing. However, recent evidence suggests high positivity yields utilizing community index case testing. In Malawi, index testing in which contacts are offered community-based HIV testing, resulted in a 3.8% yield among children up to 15 years of age [ 9 ]. Other findings from Kenya provide evidence that utilizing adolescent siblings on ART and deceased clients with known HIV infection as the index clients and hybrid community/home-based testing were effective at identifying positive children 2–14 years of age [ 12 , 42 ].

Finally, our study shows that 99% of children initiated ART. Other studies have found 65%-95% of newly diagnosed children and adolescents were linked to HIV care and treatment [ 9 , 11 , 40 ]. However, despite all children being dispensed ART following diagnosis in Uganda, four children with advanced disease at diagnosis died. Additionally, nine (5.2%) children overall made no return visits for ART refills and other services during the study period. Community-based follow-up systems could be strengthened to ensure children newly initiated on ART, particularly those with advanced disease at time of ART start, and/or their caregivers, get the adherence and other support needed. Community worker programs in Zimbabwe and South Africa were associated with improved survival and virological outcomes among children newly enrolled on ART [ 43 – 45 ].

This study has some limitations. First, we did not assess transmission mode. We excluded two children who we could classify as likely horizontal transmissions from our review of mothers’ PMTCT cascade profiles. However, it is possible other children acquired HIV through a mode other than mother- to-child transmission. While MTCT accounts for most of the infections in children, there is still a need to assess other risk factors for HIV in this age group. Secondly, because study staff were not always able to accompany health workers for community-based testing, the total number of children diagnosed as HIV-positive in communities who did not present at the health facility for care and treatment during the study period is unknown. This exclusion could have resulted in an overestimation of the linkage to treatment rate. However, the number is expected to be small, based on programmatic data from the same period that shows high ART linkage rates from community testing in Kenya and high overall linkage rates in Uganda (where rates by testing modality cannot be determined from routine data). Thirdly, we are not able to draw conclusions regarding HIV-positive yield from different testing points from the cohort, as we only enrolled HIV-positive children. Moreover, expanding our study population to HIV-exposed but uninfected children and powering the study to compare differences in adherence to the PMTCT cascade among the two groups may have strengthened these findings or provided additional insights into the gaps contributing to child infection. However, the identification of gaps and sub-optimal fidelity to PMTCT service delivery are still important findings for program improvement to minimize the risk of transmission as much as possible. Risk factors, reflecting gaps identified in this study like lack of maternal ARV, are well documented in the literature [ 46 – 49 ].

This study described multiple missed opportunities for prevention of HIV in newly diagnosed children living with HIV in Uganda and Kenya, including gaps in ANC attendance, re-testing during pregnancy and breastfeeding, and initiation of ARVs and possible delays in delivery of HIV testing services to HIV-exposed children. However, once HIV infection was diagnosed in children, nearly all children were promptly linked to treatment. Findings support improving PMTCT service delivery to HIV-negative women, including retesting during pregnancy and breastfeeding and emphasizing prevention messaging, strengthening referral and follow-up systems and other interventions to help ensure HIV-positive women receive ARVs in ANC and broader implementation of community-based approaches to HIV case finding to help ensure children not engaged in care receive HTS services.

Supporting information

https://doi.org/10.1371/journal.pone.0233590.s001

https://doi.org/10.1371/journal.pone.0233590.s002

Acknowledgments

We greatly appreciate the assistance provided by the study investigators, the EGPAF study coordination and data team and other EGPAF staff whose work and dedication made this study possible. The authors would like to thank the team of research assistants in both countries for their essential role in this study and the study participants, without whom this research would not be possible. We also wish to acknowledge the essential cooperation of the Ministries of Health centrally and at the county and district levels in Kenya and Uganda, respectively. Finally, thank you to USAID and Population Council/Project SOAR for their support throughout this study.

  • 1. UNAIDS. Fact Sheet–World AIDS Day 2018. Geneva: UNAIDS; 2017. Available from: www.unaids.org/sites/default/files/media_asset/UNAIDS_FactSheet_en.pdf .
  • 2. WHO. Progress Report 2016: Prevent HIV, Test and Treat All, WHO Support for Country Impact. Geneva: UNAIDS; 2016. Available from: apps.who.int/iris/bitstream/10665/251713/1/WHO-HIV-2016.24-eng.pdf .
  • View Article
  • Google Scholar
  • 4. UNAIDS. Miles to Go—Global AIDS Update 2018. Geneva: UNAIDS; 2018. Available from: www.unaids.org/sites/default/files/media_asset/miles-to-go_en.pdf .
  • 10. The President's Emergency Plan for AIDS Relief (PEPFAR). Partner and Family-Based Index Case Testing: A Standard Operating Procedure. Available from: aidsfree.usaid.gov/sites/default/files/pn_sop_slides.pdf.
  • 14. Kenya Ministry of Health (MOH) and National AIDS and STI Control Programme (NASCOP). Kenya HIV Estimates, Report 2018. Nairobi: Kenya MOH; 2018. Available from: nacc.or.ke/wp-content/uploads/2018/11/HIV-estimates-report-Kenya-20182.pdf.
  • 15. Uganda Population-Based HIV Impact Assessment. Extended Summary Sheet: Preliminary Findings. 2018. Available from: phia.icap.columbia.edu/wp-content/uploads/2018/07/3430%E2%80%A2PHIA-Uganda-SS_NEW.v14.pdf https://dhsprogram.com/pubs/pdf/AIS10/AIS10.pdf .
  • 16. UNAIDS. Country Factsheets: Kenya. Geneva: UNAIDS; 2017. Available from: www.unaids.org/en/regionscountries/countries/Kenya .
  • 17. UNAIDS. Country Factsheets: Uganda. Geneva: UNAIDS; 2017. Available from: www.unaids.org/en/regionscountries/countries/uganda .
  • 18. Kenya MOH and NASCOP. Guidelines on use of antiretroviral drugs for treating and preventing HIV infection in Kenya 2016 Edition. Nairobi: NASCOP; 2018. Available from: www.prepwatch.org/wp-content/uploads/2016/08/Guidelines-on-ARV-for-Treating-Preventing-HIV-Infections-in-Kenya.pdf .
  • 19. Uganda MOH. Consolidated Guidelines for Prevention and Treatment of HIV in Uganda. Kampala: Uganda MOH; 2016. Available from: aidsfree.usaid.gov/sites/default/files/uganda_hiv_gl_2016.pdf .
  • 20. Kenya National Bureau of Statistics, MOH, National AIDS Control Council, the National Council for Population and Development and the Kenya Medical Research Institute. Kenya Demographic and Health Survey 2014. Nairobi and Rockville: Kenya National Bureau of Statistics and ICF; 2015. Available from: dhsprogram.com/pubs/pdf/FR308/FR308.pdf.
  • 21. Uganda Bureau of Statistics (UBOS) and ICF. Uganda Demographic and Health Survey 2016. Kampala and Rockville: UBOS and ICF; 2018. Available from: dhsprogram.com/pubs/pdf/FR333/FR333.pdf.
  • 22. Kenya MOH, National AIDS & STI Control Programme. Guidelines on use of antiretroviral drugs for treating and preventing HIV infection in Kenya 2018 Edition. Nairobi: NASCOP; 2018. Available from: cquin.icap.columbia.edu/wp-content/uploads/2017/04/ICAP_CQUIN_Kenya-ARV-Guidelines-2018-Final_20thAug2018.pdf.
  • 23. Uganda MOH. National HIV Testing Services Policy and Implementation Guidelines Uganda, 4th edition, 2016. Kampala: MOH; 2016. Available from: health.go.ug/content/national-hiv-testing-services-policy-and-implementation-guidelines .
  • 30. Uganda MOH. Addendum to the National Antiretroviral Treatment Guidelines. Kampala: MOH; 2013. Available from: aidsfree.usaid.gov/sites/default/files/tx_uganda_add_to_art_2013.pdf.
  • 31. Kenya MOH and NASCOP. Guidelines on Use of Antiretroviral Drugs for Treating and Preventing HIV Infection: A rapid advice, 2014. Nairobi: NASCOP; 2014. Available from: aidsfree.usaid.gov/sites/default/files/tx_kenya_2014.pdf.
  • 33. Webb R and Cullel MM. Understanding the perspectives and/or experiences of women living with HIV regarding Option B+ in Uganda and Malawi. Final Report. Rebekah Webb Consulting; 2013. Available from: www.gnpplus.net/assets/2013-Option-B+-Report-GNP-and-ICW.pdf .
  • 46. UNAIDS. On the Fast Track to an AIDS-Free Generation. Geneva: UNAIDS; 2016 Available from: www.unaids.org/sites/default/files/media_asset/GlobalPlan2016_en.pdf .

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Cost analysis of implementing HIV drug resistance testing in Kenya: a case study of a service delivery site at a tertiary level hospital in Kenya

Rachael w. gachogo.

1 Molecular and Infectious Diseases Research Laboratory, University of Nairobi, Nairobi, Kenya

2 School of Economics, University of Nairobi, Nairobi, Kenya

Daniel N. Mwai

Frank g. onyambu.

3 School of Health Sciences, Meru University of Science and Technology, Meru, Kenya

Associated Data

Underlying data.

Figshare: Cost analysis of implementing HIV drug resistance testing in Kenya: a case study of a service delivery site at a tertiary level hospital in Kenya: https://doi.org/10.6084/m9.figshare.12561980.v3 ( Gachogo et al. , 2020a ).

This project contains the following underlying data:

  • - HIVDR_Consumables cost.xlsx
  • - HIVDR_BuildingCost.xlsx
  • - HIVDR_Electricitycost.xlsx
  • - HIVDR_Equipment_cost.xlsx
  • - HIVDR_Indirectcost.xlsx
  • - HIVDR_Personnel_cost.xlsx
  • - HIVDR_Reagents_cost.xlsx
  • - HIDVR_Viroseq_consumbles.xlsx
  • - HIDVR_viroseq_reagents.xlsx
  • - HIVDR_Field_notes.pdf

Extended data

Figshare: Cost analysis of implementing HIV drug resistance testing in Kenya: a case study of a service delivery site at a tertiary level hospital in Kenya. https://doi.org/10.6084/m9.figshare.12628031.v1 ( Gachogo et al. , 2020b ).

  • - HIVDR_Questionnaire.pdf
  • - Interview Guide.pdf

Data are available under the terms of the Creative Commons zero “No rights reserved” data waiver (CC0 1.0 Public domain dedication).

Peer Review Summary

Background: HIV drug resistance (HIVDR) threatens progress achieved in response to the HIV epidemic. Understanding the costs of implementing HIVDR testing programs for patient management and surveillance in resource-limited settings is critical in optimizing resource allocation. Here, we estimate the unit cost of HIVDR testing and identify major cost drivers while documenting challenges and lessons learnt in implementation of HIVDR testing at a tertiary level hospital in Kenya.

Methods: We employed a mixed costing approach to estimate the costs associated with performing a HIVDR test from the provider’s perspective. Data collection involved a time and motion study of laboratory procedures and interviewing laboratory personnel and the management personnel. Cost analysis was based on estimated 1000 HIVDR tests per year. Data entry and analysis were done using Microsoft Excel and costs converted to US dollars (2019).

Results: The estimated unit cost for a HIVDR test was $271.78 per test. The main cost drivers included capital ($102.42, 37.68%) and reagents (101.50, 37.35%). Other costs included: personnel ($46.81, 17.22%), utilities ($14.69, 5.41%), equipment maintenance costs ($2.37, 0.87%) and quality assurance program ($4, 1.47%). Costs in relation to specific laboratory processes were as follows: sample collection ($2.41, 0.89%), RNA extraction ($22.79, 8.38%), amplification ($56.14, 20.66%), gel electrophoresis ($10.34, 3.80%), sequencing ($160.94, 59.22%), and sequence analysis ($19.16, 7.05%). A user-initiated modification of halving reagent volumes for some laboratory processes (amplification and sequencing) reduced the unit cost for a HIVDR test to $233.81 (13.97%) reduction. 

Conclusions: Capital expenditure and reagents remain the most expensive components of HIVDR testing. This cost is bound to change as the sequencing platform is utilized towards maximum capacity or leveraged for use with other tests. Cost saving in offering HIVDR testing services is also possible through reagent volume reduction without compromising on the quality of test results.

Unprecedented increased access to antiretroviral therapy (ART) is one of the greatest milestones in the fight against the HIV epidemic, resulting in reduced mortality from AIDs-related causes and a global decline in HIV incidence ( UNAIDS, 2019 ). However, this success is threatened by emergence of HIV drug resistance (HIVDR). The World Health Organization (WHO) reports greater than 10% pretreatment drug resistance to non-nucleoside reverse transcriptase inhibitors (NNRTIs) among adult patients starting on a first-line ART regimen. This rate is higher in children below 18 months, with over half of newly diagnosed infants harboring resistance to NNRTIs. The prevalence of acquired HIVDR among patients on ART ranges from 3% to 29% ( WHO, 2019 ). Moreover, recent studies in Kenya have shown an upward trend in both transmitted and acquired HIVDR ( Hassan et al. , 2019 ; Kantor et al. , 2018 ; Milne et al. , 2019 ).

ART is delivered through the public health approach in most low- and middle-income countries, where standardized drug regimens are administered with simplified laboratory monitoring using tests such as HIV viral load and CD4 count assays ( Lessells et al. , 2013 ; De Luca et al. , 2013 ; Phillips et al. , 2018 ). Access to HIVDR testing is limited for patients in resource-limited settings such as Kenya due to high costs involved and inadequate laboratory capacity ( Kennedy et al. , 2016 ; Nkengasong et al. , 2018 ; Petti et al. , 2006 ). On the other hand, HIVDR testing is offered routinely in resource-rich setting to inform clinical management of people living with HIV ( Dunn et al. , 2011 ; Günthard et al. , 2019 ). However, considerable effort has been made to monitor population level of HIVDR in low- and middle-income countries by implementing HIVDR surveys according to WHO guidelines. These surveys have been crucial in informing national ART guidelines; for example, data on the high prevalence of pretreatment drug resistance to NNRTIs has been critical in the transitioning from an NNRTI-based first-line regimen to a regimen that consists of dolutegravir (DTG) in sub-Saharan countries ( WHO, 2019 ).

Funding for HIV programming in Sub-Saharan countries is provided by multilateral development partners including the US President’s Emergency Plan for AIDs Relief (PEPFAR), the Global Fund and the World Bank, among others ( Ministry of Health, 2015 ; Mwai, 2017 ; Olakunde et al. , 2019 ; Schneider et al. , 2016 ). These multilateral partners have acknowledged the integral role played by quality medical laboratory services within health systems, precipitating mobilization of significant amounts of funding earmarked for laboratory systems strengthening in resource-limited settings ( Abimiku, 2009 ; Hamel et al. , 2015 ; Nkengasong et al. , 2018 ). This support has led to great improvement in HIV diagnostic and monitoring services, inter-laboratory networks, systems, governance, and institutions, evident by the increased number of laboratories that have the capacity to perform molecular diagnostics for HIV viral load and early infant diagnosis (EID), as well as HIV genotyping. Furthermore, these partners have been at the forefront in supporting development of national laboratory policy and strategic plans, and improving quality in these laboratories ( Nkengasong et al. , 2018 ; Hamel et al. , 2015 ).

In Kenya, there are 10 laboratories across the country that support HIV viral load and EID testing through a PEPFAR and Global Fund funded specimen referral network, and only four of these have capacity to perform HIVDR testing. However, there is a paucity of costing data from these laboratories and no detailed cost analysis has been done ( Inzaule et al. , 2013 ). Some of the essential costs when performing a costing analysis include equipment costs, personnel costs, and utilities costs. Previous studies have included reagents cost and consumables cost in their estimations, excluding major cost categories ( Acharya et al. , 2014 ; Inzaule et al. , 2013 ; Novitsky et al. , 2015 ; Zhou et al. , 2011 ). A detailed cost analysis provides a deeper understanding of the costs of HIVDR to the health systems. Moreover, cost information is important in development of business plans, projections, planning, budgeting, pricing and resources allocation. Finally, it gives a good guide on the affordability of HIVDR testing inclusion in the standard package of HIV testing in Kenya to alleviate the rising number of cases of HIVDR.

In this study we estimate the unit cost of HIVDR testing, identify the cost drivers for the HIVDR test, explore opportunities for cost saving and document challenges and lessons learnt in implementation of HIVDR testing.

Ethical statement

Ethical approval was obtained from University of Nairobi/Kenyatta National Ethics Review Committee (KNH-UON-ERC- P562/01/2019). Verbal informed consent was obtained from all participants for the interviews and the ethics review board waived the need for a signed consent form. the study followed the guidelines for verbal consent, including explaining to the study participants the pertinent issues about the study including the purpose, benefits, risks and procedures. The participants were also given enough time to decide whether to participate or not as well as an opportunity to ask questions.

This costing study was conducted at the Molecular and Infectious Diseases Research Laboratory (MIDRL) located within the Kenyatta National Hospital and University of Nairobi School of Medicine. The MIDRL supports the implementation of high quality, sustainable and comprehensive HIV prevention, care and treatment in Nairobi through provision of laboratory services including HIV viral load, HIV early infant diagnosis and HIVDR testing. Data collection was performed during the initial implementation stages, that is within the first year of commencing HIVDR testing.

Costing methodology

The study utilized both micro and gross costing in quantification and valuation of the cost categories, which was done from the provider’s perspective.

Data collection and analysis

Data were collected and compiled from 1 st January to 30 th June 2019. Costs were assessed for various processes in the HIVDR testing workflow including laboratory administration, sample collection and preparation, viral RNA extraction, nucleic acid amplification, gel electrophoresis, Sanger sequencing, data analysis and reporting. At the time of data collection, the laboratory used a commercial HIVDR assay supplied by Thermofisher (Cat. no. 12183018A, Waltham, USA). Cost data were collected on annualized depreciation for capital items including laboratory equipment and furniture, long term training and information technology equipment at a depreciation rate of 10%, reagents and consumables, personnel, utilities, laboratory and office space, quality assurance program, and maintenance costs. Cost details were obtained from quotations, invoices and delivery notes.

Data was collected by RG, who at the time of the study was working at MDRL as a clinical laboratory assistant and a master’s student (Health Economics and Policy) at the University of Nairobi. Data collection involved a time and motion study of the laboratory procedures for HIVDR testing and interviewing of laboratory and management personnel. The time and motion study was carried out in 12 sessions lasting between 1–3 hours based on the length of the laboratory procedure. A structured questionnaire depicting all the HIVDR testing steps and data collection tables were used to document quantity of reagents and consumables used as well as duration of each HIVDR process ( Gachogo et al. , 2020b ). Two laboratory technical staff and one member of management were interviewed in three sessions (1 hour) each. Individuals with in-depth knowledge on HIVDR testing implementation were purposively selected to participate in the interviews. Interviews took place within their work environment. An interview guide was used to conduct the interview process and the data was recorded in form of field notes ( Gachogo et al. , 2020b ). Technical staff were interviewed about HIVDR testing processes and experiences of implementing testing, while the member of management was interviewed about cost data, which was recorded in the data collection tables. None of the interviewees declined to participate. Administrative records such as invoices, requests for quotations and delivery notes obtained from the program archives were reviewed to obtain purchase costs. In addition, the laboratory personnel were asked to narrate their experience in setting up a HIVDR testing laboratory, with particular interest on problems encountered and solutions to these set-backs.

Data analysis

We developed a Microsoft Excel version 2010 based model to aid in estimation of the unit cost and cost for the various categories and laboratory processes. All costs were converted to US dollars (13 th April 2019, $1 USD = 101.2 Kshs). The MIDRL projected to perform 1000 tests in 2019 based on the number of HIVDR tests performed in the first and second quarter of the 2019 financial year. Responses on challenges experienced during the implementation of HIVDR testing were manually scanned through by RG and FO for developing themes and coded accordingly.

Sensitivity analysis

One-way sensitivity analysis for 20% variations to cost categories was performed to establish the level of uncertainty linked with costs variation of inputs to HIVDR test. This involved varying capital, personnel, reagents, maintenance, and quality assurance program costs by ±20% and evaluating how each of them influence the HIVDR unit cost relative to the estimated cost.

HIVDR testing process

HIVDR testing is carried out in five major processes; namely, sample collection and preparation, nucleic acid extraction, nucleic acid amplification, sequencing and sequence analysis. Specimen collection and preparation involves collection of whole blood from the patient into blood collection tubes that contain ethylenediaminetetraacetic acid (EDTA) anticoagulant. Once the blood is collected into the blood collection tubes, the specimen is prepared for storage by spinning, pipetting and aliquoting into storage vials. The second step in HIV resistance testing is nucleic acid extraction from the plasma. In this step, HIV ribonucleic acid (RNA) is isolated from plasma. Once extracted and purified, the nucleic acid is converted to complementary deoxy-ribonucleic acid (cDNA) and amplified by polymerase chain reaction (PCR) and sequenced. Sequencing involves amplicon purification, cycle sequencing, amplicon purification, sequence detection and visualization. The last step in HIVDR testing is sequence analysis, which involves sequence data validation, sequence assembly, interpretation and quality analysis.

HIVDR unit cost

Activity-based costing for HIVDR testing was performed at MIDR Laboratory by collecting cost data for each step in the drug resistance testing. The cost for performing HIVDR testing was US$ 271.78 per test, where capital costs took the biggest share at $102.42, followed by reagents and consumables at $101.5 ( Table 1 and Figure 1 ). Other costs included personnel ($46.81), utilities ($14.69), maintenance cost of equipment ($2.37) and quality assurance program ($4.00) ( Gachogo et al. , 2020a ).

Costs in USD.

* The most costly component of HIV resistance testing.

An external file that holds a picture, illustration, etc.
Object name is f1000research-9-25806-g0000.jpg

Unit cost is $271.8.

Cost per laboratory process

The sequencing step had the largest cost of $160.94 per test, while DNA/RNA amplification had the second largest cost of $56.14. DNA/RNA extraction, gel electrophoresis, sequence analysis and sample collection had a cost of $22.79, $10.34, $19.16 and $2.41, respectively ( Table 2 and Figure 2 ).

* The most expensive step in HIV drug resistance testing.

An external file that holds a picture, illustration, etc.
Object name is f1000research-9-25806-g0001.jpg

Unit cost is $271.78.

Cost of the modified HIVDR assay

The laboratory validated a low-cost assay, whereby reagents volumes used during the amplification and sequencing steps were half the recommended volumes by the manufacturer. The test performance was in agreement with the original assay as previously reported ( Magomere et al. , 2019 ). The unit cost as a result of halving reagents volumes at the amplification and sequencing step was $233.81, a reduction from $271.78 of the original assay. There was a notable reduction for the amplification and sequencing costs to $38.38 and $140.70 from $56.14 and $160.94, respectively. There was no change in costs for the other steps in HIVDR testing ( Table 3 and Figure 3 ).

1 Halving reagent volumes at DNA/RNA amplification step reduces the cost of this step from $56.14 to $38.38.

2 Halving reagent volumes at sequencing step reduces the cost of this step from $160.94 to 140.70.

3 Halving reagent volumes at DNA/RNA amplification and sequencing steps reduce the HIV drug resistance test cost to $ 233.81 from $ 271.78.

An external file that holds a picture, illustration, etc.
Object name is f1000research-9-25806-g0002.jpg

Total unit cost is $233.81.

Cost of HIVDR test using US Food and Drug Administration (FDA)-approved assay

The cost for the HIVDR test using Viroseq HIV genotyping reagents and consumables (Abbott Molecular, Abbott Park, IL) was estimated at $379.46. This is one of the FDA-approved HIVDR tests available on the market and is used as an alternative to in-house reagents and consumables manufactured by Thermofisher. Reagents and consumables accounted for 55% ($209.18) of the unit cost of the HIVDR testing ( Table 4 ).

* Reagents and consumables are the most expensive inputs to HIV drug resistance testing in Viroseq HIV genotyping.

Challenges and lessons learnt.

As a startup laboratory, the challenges and lessons learnt during the processes of establishing such a capital-intensive undertaking in a resource-limited setting were documented. Table 5 shows some of the challenges and lessons learnt.

The costs presented assume that the laboratory runs 1000 HIVDR tests per year with no machine breakdown or waste of supplies. Considering that variation in input costs would have an impact on the input costs, a one-way sensitivity analysis for 20% variations to cost categories was performed. Variations to capital, reagents, and personnel inputs had a major impact on the unit cost, whereas variations to utilities, maintenance and quality assurance results had no significant impact on the unit cost. A 20% variation to capital and reagents results in changes of up to 7.5% in unit cost; approximately a $20 difference ( Figure 4 ).

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Grey represents 20% reduction in the input costs, while dark grey represents 20% increase in the input costs. Unit cost is $271.78.

The aim of this study was to establish a detailed cost profile for HIVDR testing from a provider’s perspective and identify cost drivers. We also report the challenges encountered and lessons learnt during the implementation of HIVDR testing at the MIDRL. The cost of performing HIVDR testing was estimated to be $271.78 per test. The cost estimate represents all the inputs required for performing HIVDR testing including; capital, personnel, reagents, consumables, quality assurance program and service contracts for the laboratory equipment for performing 1000 tests per year. Previous studies did not include all cost categories, making it difficult to compare costs for offering drug resistant tests across many laboratories ( Acharya et al. , 2014 ; Alemán et al. , 2015 ; Inzaule et al. , 2013 ; Novitsky et al. , 2015 ). In this study, we offer a framework for performing laboratory cost analyses that makes it easy to compare cost categories between different laboratories. A previous study from KEMRI/CDC, Kenya, performed a cost analysis of their in-house assay and established the unit cost to be approximately $113.33, with $109.31 as the cost of reagents and consumables ( Inzaule et al. , 2013 ). The analysis included the costs of reagents and consumables and the cost of maintaining the equipment but did not account for capital, personnel and external quality assurance program costs. Considering the reagent and consumable costs, there was a correlation in the cost results for these items, as our study estimated the cost to be $101.50. The slight difference could be attributed to time difference in performing the cost analysis. In addition, the previous study estimated the equipment maintenance cost to be $4.02, while the present study estimates a cost of $2.37 for this category. Some of the studies performed in other parts of the world found considerably lower reagents and consumables costs than those estimated by this study. For instance, the costs reported in India and Cuba were $85.00 and $87.80, respectively ( Acharya et al. , 2014 ; Alemán et al. , 2015 ). Conversely, one study reported higher reagent costs than those found in the present study; the estimated cost was $139.75 per test ( Novitsky et al. , 2015 ).

To answer the question of the cost drivers for HIVDR testing, the costs were categorized according to the processes involved in HIVDR testing, including sample collection, RNA extraction and amplification, gel electrophoresis, sequencing, and sequencing analysis. In terms of cost categories, capital cost took the biggest share of pie at $102.42 (37.68%), followed by reagents plus consumables at $101.50 (37.35%). High capital costs could be attributed to sub-optimal utilization of the sequencing platform. It should be noted that the equipment required for HIVDR testing can be leveraged to perform more patient tests that support HIV care and treatment, therefore bringing down the cost of equipment attributed to HIVDR testing. Our cost analysis was based on an estimated projection of 1000 HIVDR tests per year, which is a gross underestimation of the laboratory’s capacity. If the laboratory operated optimally, offering approximately ~6720 tests per year, the capital cost would reduce ~6.7 fold. The reagent costs were considerably high as a result of acquiring the sequencing machine at no upfront cost. This bound the laboratory to only procure reagents and consumables from the machine provider. This commitment denies the laboratory an opportunity to practice strategic purchasing, which would be a key factor in lowering the cost of reagents. This is not unique to HIVDR testing; a study done in Kenya to estimate cost of HIV viral load and EID reported high reagent costs as a result of machine acquisition on a placement basis ( Cintron et al. , 2017 ).

A comparison with other studies was impossible as most of the previous cost analysis included reagents and consumables costs only, omitting other categories such as capital, personnel, utilities and quality control program costs ( Alemán et al. , 2015 ; Inzaule et al. , 2013 ; Novitsky et al. , 2015 ). In terms of cost per process, the sequencing step, which involves purification of PCR products, cycle sequencing, purification of sequencing products and sequence detection, was the most costly step in HIVDR testing at $160.94 (59.22%). This is in keeping with other studies evaluating the cost of HIVDR testing. Other studies report $59.88 (52.92%) and $50 (58.82%) as the cost for the sequencing step ( Acharya et al. , 2014 ; Inzaule et al. , 2013 ). The one-way sensitivity analysis performed illustrates a cost saving opportunity, for example through negotiating lower reagent prices and maximizing utilization of the sequencing platform, therefore ensuring sustainable use of health financing resources.

Comparing the cost of the HIVDR test to a HIV viral load test used in monitoring and management of people living with HIV, the HIVDR testing cost is higher. A study in Kenya estimates HIV viral load test at $24.63 for non-point-of-care viral load testing and $29.74 for point-of-care HIV viral load testing ( Cintron et al. , 2017 ). This is attributed to additional processes in HIVDR test, that is, nested PCR and cycle sequencing processes. These increase the amount of cost inputs used in HIVDR testing, especially staff hands-on time.

The study evaluated the effects of reducing the reagents volume on the cost and performance characteristics of the HIVDR testing in view of reagents being one of the cost drivers for HIVDR testing. On the cost of the HIVDR testing, there was a significant reduction in the cost from $271.78 to $247.30; a ~13.97% reduction in the cost per test. This assay modification led to a ~37.68% reduction in reagent costs. Of note is the concordance of the two assays in their performance characteristics, which increases the confidence in adoption of this cost saving undertaking by the laboratories that would like to increase their efficiency in offering the HIVDR testing service ( Magomere et al. , 2019 ). The new assay performance characteristics met the WHO HIVDR validation criteria ( WHO, 2018 ). Cost computation using Viroseq reagents, which are FDA approved and an alternative to in-house Thermofisher (Illinois, US) reagents, gave a cost of $379.46 per test, with reagents taking the biggest share of the cost at 55.13% ($209.18). This illustrates a lower cost of HIVDR testing using Thermofisher reagents by $107.68. These findings are in keeping with other studies where the cost of HIVDR per test was lower when using the in-house system compared to the Viroseq system ( Acharya et al. , 2014 ; Inzaule et al. , 2013 ; Zhou et al. , 2011 ). For instance, one study reported a $132.86 difference in the two systems, while another reported a $165.01 difference ( Inzaule et al. , 2013 ).

One of the challenges encountered during the implementation of HIVDR testing was high staff turnover. This is attributed to advanced molecular skills required for sample analysis in HIVDR testing. There are a few laboratory specialists equipped with these skills, making them highly sought after in the job market. This is a challenge in a low resource set up as training personnel on this area is quite expensive ( Abimiku, 2009 ; Kennedy et al. , 2016 ; Nkengasong et al. , 2018 ; WHO, 2010 ). To counteract this challenge, one of the staff won a training grant to learn HIVDR testing from a laboratory that was already established. The sequencing machine provider is also bound by the contract to train the laboratory staff to the highest level possible and provide machine service when due. Maintaining a good working relationship with other laboratories performing the test helps in the exchange of new ideas and also facilitates an inter-laboratory proficiency testing program.

Unlike HIV viral load and EID, HIVDR testing is not included in the Global Access Program, which has helped in the scaling up of HIV viral load and EID testing in Kenya at a relatively low cost ( WHO, 2014 ). This raises sustainability concerns owing to recent reduced donor funding for HIV programs. However, HIVDR testing services can leverage on already established sample referral networks, human resources, laboratory equipment and database for HIV viral load. The multiple possible applications of the sequencing platform provides opportunities to deploy it for other tests and services, therefore reducing the overall running costs. Sensitization of key stakeholders involved in management of people living with HIV through regular stakeholders meetings has been instrumental in uptake of HIVDR test.

Other challenges experienced during the implementation of drug resistance testing included frequent electricity disconnections, which was solved by installing a backup generator to ensure a constant supply of power. This corroborates other previous studies that highlighted similar findings in resource limited settings ( Kennedy et al. , 2016 ; Nkengasong et al. , 2018 ). Furthermore, supply chain insufficiency, which delayed timely delivery of reagents, consumables, and laboratory equipment, was a major setback in implementing HIVDR testing. Finally, the premixed PCR master-mixes limited the flexibility of their use for other tests.

Strengths of the study

This report presents findings from a complete cost analysis performed in the early stages of implementation of HIVDR testing, hence giving a good picture of the costs involved in the process. This report will further serve as a useful resource for planning and budgeting information for better resource management for similar projects in future. The inclusion of the cost-saving assay evaluation makes the study one of a kind, as it provides an evidence of cost reduction and comparable performance characteristics for both assays.

Study limitations

The study estimated costs from the provider’s perspective, thus limiting the inclusion of cost incurred by patients. The study design also excluded transport costs incurred for the transport of samples from peripheral health facilities to the testing laboratory in Nairobi. Furthermore, the cost analysis was carried out in only one facility, hence hindering the comparison across facilities offering HIVDR testing. This study presents a partial economic evaluation; a complete economic evaluation would give a clearer picture on the cost-effectiveness of HIVDR testing versus the status quo. Finally, at the time of the study the laboratory was not operating at full capacity, which increases the unit cost of HIVDR testing. It is conceivable that once uptake for the HIVDR test increases, the additional volumes would translate to reduced costs.

The MIDRL has implemented HIVDR testing capacity for patients failing ART at a cost of $271.78 per test. The most important cost driver is expenditure on capital cost, which is likely to reduce when utilization of the equipment increases. It has also been demonstrated that there are opportunities for cost saving through assay modifications such as selective reagent volume reduction.

Data availability

[version 1; peer review: 2 approved]

Funding Statement

The author(s) declared that no grants were involved in supporting this work.

  • Abimiku AG, Institute of Human Virology, University of Maryland School of Medicine PEPFAR Program (AIDS Care Treatment in Nigeria [ACTION]) : Building laboratory infrastructure to support scale-up of HIV/AIDS treatment, care, and prevention: In-country experience. Am J Clin Pathol. 2009; 131 ( 6 ):875–886. 10.1309/AJCPELMG6GX6RQSM [ PubMed ] [ CrossRef ] [ Google Scholar ]
  • Acharya A, Vaniawala S, Shah P, et al.: Development, Validation and Clinical Evaluation of a Low Cost In-House HIV-1 Drug Resistance Genotyping Assay for Indian Patients. PLoS One. 2014; 9 ( 8 ):e105790. 10.1371/journal.pone.0105790 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
  • Alemán Y, Vinken L, Kourí V, et al.: Performance of an in-house human immunodeficiency virus type 1 genotyping system for assessment of drug resistance in Cuba . PLoS One. 2015; 10 ( 2 ):e0117176. 10.1371/journal.pone.0117176 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
  • Cintron C, Mudhune V, Haider R, et al.: Costs of Hiv Viral Load and Early Infant Diagnosis Testing in Kenya .2017. Reference Source [ Google Scholar ]
  • De Luca A, Hamers RL, Schapiro JM: Antiretroviral Treatment Sequencing Strategies to Overcome HIV Type 1 Drug Resistance in Adolescents and Adults in Low-Middle-Income Countries. J Infect Dis. 2013; 207 ( Suppl 2 ):S63–9. 10.1093/infdis/jit109 [ PubMed ] [ CrossRef ] [ Google Scholar ]
  • Dunn DT, Coughlin K, Cane PA: Genotypic resistance testing in routine clinical care. Curr Opin HIV AIDS. 2011; 6 ( 4 ):251–257. 10.1097/COH.0b013e32834732e8 [ PubMed ] [ CrossRef ] [ Google Scholar ]
  • Gachogo R, Mwai D, Onyambu F: Cost analysis of implementing HIV drug resistance testing in Kenya: a case study of a service delivery site at a tertiary level hospital in Kenya. figshare. Dataset.2020a. 10.6084/m9.figshare.12561980.v3 [ CrossRef ] [ Google Scholar ]
  • Gachogo R, Mwai D, Onyambu F: Cost analysis of implementing HIV drug resistance testing in Kenya: a case study of a service delivery site at a tertiary level hospital in Kenya. figshare. Dataset.2020b. 10.6084/m9.figshare.12628031.v1 [ CrossRef ] [ Google Scholar ]
  • Günthard HF, Calvez V, Paredes R, et al.: Human Immunodeficiency Virus Drug Resistance: 2018 Recommendations of the International Antiviral Society - USA Panel. Clin Infect Dis. 2019; 68 ( 2 ):177–187. 10.1093/cid/ciy463 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
  • Hamel DJ, Sankalé JL, Samuels JO, et al.: Building laboratory capacity to support HIV care in Nigeria: Harvard / APIN PEPFAR, 2004–2012. Afr J Lab Med. 2015; 4 ( 1 ):190. 10.4102/ajlm.v4i1.190 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
  • Hassan AS, Bibby DF, Mwaringa SM, et al.: Presence, persistence and effects of pre-treatment HIV-1 drug resistance variants detected using next generation sequencing: A Retrospective longitudinal study from rural coastal Kenya. PLoS One. 2019; 14 ( 2 ):e0210559. 10.1371/journal.pone.0210559 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
  • Inzaule S, Yang C, Kasembeli A, et al.: Field Evaluation of a Broadly Sensitive HIV-1 In-House Genotyping Assay for Use with both Plasma and Dried Blood Spot Specimens in a Resource-Limited Country. J Clin Microbiol. 2013; 51 ( 2 ):529–539. 10.1128/JCM.02347-12 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
  • Kantor R, Delong A, Schreier L, et al.: HIV-1 second-line failure and drug resistance at high-level and low-level viremia in Western Kenya. AIDS. 2018; 32 ( 17 ):2485–2496. 10.1097/QAD.0000000000001964 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
  • Kennedy SB, Dogba JB, Wasunna CL, et al.: Pre-Ebola virus disease laboratory system and related challenges in Liberia. Afr J Lab Med. 2016; 5 ( 3 ):508. 10.4102/ajlm.v5i3.508 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
  • Lessells RJ, Avalos A, de Oliveira T: Implementing HIV-1 Genotypic Resistance Testing in Antiretroviral Therapy Programs in Africa: Needs, Opportunities, and Challenges. AIDS Rev. 2013; 15 ( 4 ):221–229. [ PMC free article ] [ PubMed ] [ Google Scholar ]
  • Magomere EO, Nyangahu DD, Kimoloi S, et al.: Performance characteristics of a modified HIV-1 drug resistance genotyping method for use in resource-limited settings [version 1; peer review: 2 approved]. F1000Res. 2019; 8 :15181 10.12688/f1000research.20083.1 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
  • Milne RS, Silverman RA, Beck IA, et al.: Minority and majority pretreatment HIV-1 drug resistance associated with failure of first-line nonnucleoside reverse-transcriptase inhibitor antiretroviral therapy in Kenyan women. AIDS. 2019; 33 ( 6 ):941–951. 10.1097/QAD.0000000000002134 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
  • Ministry of Health: Kenya Nationl health accounts 2012/2013 .2015. Reference Source [ Google Scholar ]
  • Mwai D: Kenya National Health Accounts FY 2015/16 Republic of Kenya Ministry of Health .2017. 10.13140/RG.2.2.20647.65448 [ CrossRef ] [ Google Scholar ]
  • Nkengasong JN, Peeling RW, Yao K, et al.: Personal View Laboratory medicine in Africa since 2008 : then , now , and the future. Lancet Infect Dis. 2018; 3099 ( 18 ):1–6. 10.1016/S1473-3099(18)30120-8 [ PubMed ] [ CrossRef ] [ Google Scholar ]
  • Novitsky V, Zahralban-steele M, Mclane F: Long-Range HIV Genotyping Using Viral RNA and Proviral DNA for Analysis of HIV Drug Resistance and HIV Clustering. J Clin Microbiol. 2015; 53 ( 8 ):2581–2593. 10.1128/JCM.00756-15 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
  • Olakunde BO, Adeyinka DA, Ozigbu CE, et al.: Revisiting aid dependency for HIV programs in Sub-Saharan Africa. Public Health. 2019; 170 :57–60. 10.1016/j.puhe.2019.02.016 [ PubMed ] [ CrossRef ] [ Google Scholar ]
  • Petti CA, Polage CR, Quinn TC, et al.: Laboratory Medicine in Africa: A Barrier to Effective Health Care. Clin Infect Dis. 2006; 42 ( 3 ):377–382. 10.1086/499363 [ PubMed ] [ CrossRef ] [ Google Scholar ]
  • Phillips AN, Cambiano V, Nakagawa F, et al.: Cost-effectiveness of public-health policy options in the presence of pretreatment NNRTI drug resistance in sub-Saharan Africa: a modelling study. Lancet HIV. 2018; 5 ( 3 ):e146–e154. 10.1016/S2352-3018(17)30190-X [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
  • Schneider MT, Birger M, Haakenstad A, et al.: Tracking development assistance for HIV/AIDS: the international response to a global epidemic. AIDs. 2016; 30 :1475–1479. 10.1097/QAD.0000000000001081 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
  • UNAIDS: UNAIDS DATA 2019 .2019. Reference Source [ Google Scholar ]
  • WHO: Recommended Methods for Validation of an In-House Genotyping Assay for Surveillance of HIV Drug Resistance .2018. [ Google Scholar ]
  • WHO: Technical and Operational Considerations for Implementing HIV Viral Load Testing .2014. Reference Source [ Google Scholar ]
  • WHO: WHO/HIV RESNET HIV drug resistance laboratory strategy .2010. Reference Source [ Google Scholar ]
  • WHO: Hiv drug resistance report 2019 .2019. Reference Source [ Google Scholar ]
  • Zhou Z, Wagar N, DeVos JR, et al.: Optimization of a low cost and broadly sensitive genotyping assay for HIV-1 drug resistance surveillance and monitoring in resource-limited settings. PLoS One. 2011; 6 ( 11 ):e28184. 10.1371/journal.pone.0028184 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]

Reviewer response for version 1

Joses muthuri kirigia.

1 African Sustainable Development Research Consortium (ASDRC), Nairobi, Kenya

Recommendation to the Editor:

This is an important and pertinent manuscript in the ongoing fight against HIV/AIDS. The estimated unit cost is important for planning and budgeting purposes. Therefore, I recommend acceptance after some minor suggested revisions.

Research Article

Yes. It is a cost analysis of HIV drug resistance tests study in Kenya.

Yes. However, I suggest that the authors explain more about the method used to estimate the annual cost of capital inputs. Please see the detailed suggestion to the authors below.

The statistical analysis is not applicable for this kind of study.

Yes, the study references the repository (figshare) where data has been deposited.

Yes, the conclusions are adequately supported by the results.

Other discretionary suggestions for the authors

“A user-initiated modification of halving reagent volumes for some laboratory processes (amplification and sequencing) reduced the unit cost for a HIVDR test to $233.81, i.e. a 13.97% reduction.”

  • No amendment suggested.
  • On page 3, first paragraph, the third sentence reads “Cost data were collected on annualized depreciation for capital items including laboratory equipment and furniture, long term training and information technology equipment at a depreciation rate of 10%, …”.

As Drummond et al explain, there are two best methods costing capital inputs: (1) To calculate the equivalent annual cost, i.e. annuitize the initial cost of purchase of equipment (or building) over its useful life (years). In calculating the equivalent annual cost, one should take into account both the capital input useful life (in years) and a discount rate.

(2) Where competitive market exists to use the rent (per square metre) for building space, and lease price for equipment. The rental and lease price would capture both the depreciation and the opportunity cost.

The accounting approach of dividing the price of a capital input by the length of its useful life does not capture fully the two cost components mentioned above.

Reference: Drummond MF, Sculpher MJ, Torrance GW, O’Brien BJ, Stoddard GL. Methods for the economic evaluation of health care programmes (3 rd Edition). Oxford: Oxford University Press; 2005. 1

In Drummond et al. , refer to pages 64 and 65 for explanation and pages 72-75 for the formula for estimating the equivalent annual cost of a capital item.

  • Suggestion (B): Authors should justify the choice discount rate of 10%. The authors cite a published article that has used the same discount rate, and that would suffice.
  • Suggestion (C): On page 3, first paragraph, the fourth sentence reads “Cost details were obtained from quotations, invoices and delivery notes.” Please replace the word “Cost” at the beginning of the sentence to “Price”.

“We developed a costing model in Excel Software (Microsoft, New York) to aid in the estimation of the unit cost and cost for the various categories and laboratory processes.”

  • Page 4: The first sentence in this subsection reads “One-way sensitivity analysis for 20% variations to cost categories was performed…”. Authors could cite published studies to justify the choice of 20% variation.
  • Suggestion (A): Page 4: I suggest that the authors consider moving subsection titled “HIVDR testing process” and the first sentence of subsection titled “HIVDR unit cost” to the methods section.
  • Suggestion (B): Slightly amend the Title of Table 1 to read as: “ Table 1. Cost breakdown for each category (US$) ” Please reflect the minor amendment in Tables 2, 3, and 4.
  • Suggestion (C): The Figures 1, 2, 3, and 4 portray results that are already contained in Tables 1, 2, 3, and 4. Therefore, I suggest for authors to choose between presenting results either Tables or Figures.
  • Suggestion (A): Page 5: Please move the first sentence to methods section.
  • Suggestion (B): Page 5: Insert the percentage change of “13.97%” into the second sentence. Such that it reads as follows: “The unit cost as a result of halving reagents volumes at the amplification and sequencing step was $233.81, a 13.97% reduction from $271.78 of the original assay.”

Challenges and lessons learnt

  • Suggestion: Page 5: In the sensitivity analysis subsection, please delete the first two sentences because they were already stated in Methods.
  • Page 5: The ninth sentence reads as “Considering the reagent and consumable costs, there was a correlation in the cost results for these items, as our study estimated the cost to be $101.50.”
  • Suggestion (A): Please reword the sentence to remove the word “correlation”. I guess you want to say that your finding is very similar to those from cited studies. Correlation is a statistical term.

Page 9: In the second paragraph, the second and third sentences read as “On the cost of the HIVDR testing, there was a significant reduction in the cost from $271.78 to $247.30; a ~13.97% reduction in the cost per test. This assay modification led to a ~37.68% reduction in reagent costs.”.

  • Suggestion (C): Page 9: In the Results section, I could not find the result of $247.30. The percentage change from $271.78 to $247.30 is not ~13.97% but 9.1%. Also, I wonder whether the use of the symbol “~” is appropriate. Please check.
  • Suggestion (D): Page 9: Should the third sentence read as follows “Unlike HIV viral load and EID, HIVDR testing is not included in the Global Access Program, which could have helped in the scaling up of HIV viral load and EID testing in Kenya at a relatively low cost (WHO, 2014).” Incase, the sentence is correct as it was, please ignore this suggestion.
  • Page 9: Please consider modifying the first and second sentences as follows: “The MIDRL has implemented HIVDR testing capacity for patients with resistance to ART at a cost of $271.78 per test. The most important cost driver is expenditure on capital inputs , which is likely to reduce when utilization of the equipment increases.”

Is the work clearly and accurately presented and does it cite the current literature?

If applicable, is the statistical analysis and its interpretation appropriate?

Not applicable

Are all the source data underlying the results available to ensure full reproducibility?

Is the study design appropriate and is the work technically sound?

Are the conclusions drawn adequately supported by the results?

Are sufficient details of methods and analysis provided to allow replication by others?

Reviewer Expertise:

Economic evaluation; cost-effectiveness analysis; cost-utility analysis; cost-benefit analysis; hospital and programme costing; health financing; health economics; health systems performance assessment; national health research systems

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

Graeme Jacobs

1 Division of Medical Virology, Department of Pathology, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa

  • The study analysed the costs involved for HIVDR testing in Nairobi, Kenya. Such studies are vital to maximize the use of available resources for laboratory assays, and to help optimize the success of HIV antiretroviral therapy outcomes.
  • AIDs – S should be capital letter - AIDS.
  • It should be noted that adherence is also a threat to the success of ART, along with the development of resistance.
  • CD4 cell counts are not recommended anymore – test-and-treat campaigns.
  • Say that DTG is an Integrase Inhibitor.
  • The study gives an overall adequate outline of the major costs involved for HIVDR. As newer technologies, such as Next-generation sequencing, become more freely available (and cheaper), cost analyses studies can be re-evaluated.

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  • Nelson Kalema 3 ,
  • Charles Kabugo 1 &
  • Fred C. Semitala 2 , 4  

BMC Infectious Diseases volume  24 , Article number:  239 ( 2024 ) Cite this article

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Hospital admission outcomes for people living with HIV (PLHIV) in resource-limited settings are understudied. We describe in-hospital mortality and associated clinical-demographic factors among PLHIV admitted at a tertiary-level public hospital in Uganda.

We performed a cross-sectional analysis of routinely collected data for PLHIV admitted at Kiruddu National Referral Hospital between March 2020 and March 2023. We estimated the proportion of PLHIV who had died during hospitalization and performed logistic regression modelling to identify predictors of mortality.

Of the 5,827 hospitalized PLHIV, the median age was 39 years (interquartile range [IQR] 31–49) and 3,293 (56.51%) were female. The median CD4 + cell count was 109 cells/µL (IQR 25–343). At admission, 3,710 (63.67%) were active on antiretroviral therapy (ART); 1,144 (19.63%) had interrupted ART > 3 months and 973 (16.70%) were ART naïve. In-hospital mortality was 26% (1,524) with a median time-to-death of 3 days (IQR 1–7). Factors associated with mortality (with adjusted odds ratios) included ART interruption, 1.33, 95% confidence intervals (CI) 1.13–1.57, p 0.001; CD4 + counts ≤ 200 cells/µL 1.59, 95%CI 1.33–1.91, p  < 0.001; undocumented CD4 + cell count status 2.08, 95%CI 1.73–2.50, p  < 0.001; impaired function status 7.35, 95%CI 6.42–8.41, p  < 0.001; COVID-19 1.70, 95%CI 1.22–2.37, p 0.002; liver disease 1.77, 95%CI 1.36–2.30, p  < 0.001; co-infections 1.53, 95%CI 1.32–1.78, p  < 0.001; home address > 20 km from hospital 1.23, 95%CI 1.04–1.46, p 0.014; hospital readmission 0.7, 95%CI 0.56–0.88, p 0.002; chronic lung disease 0.62, 95%CI 0.41–0.92, p 0.019; and neurologic disease 0.46, 95%CI 0.32–0.68, p  < 0.001.

One in four admitted PLHIV die during hospitalization. Identification of risk factors (such as ART interruption, function impairment, low/undocumented CD4 + cell count), early diagnosis and treatment of co-infections and liver disease could improve outcomes.

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Introduction

Access to antiretroviral therapy (ART) has significantly decreased the global deaths associated with the Human Immunodeficiency virus (HIV) infection. More than 29 million people living with HIV (PLHIV) were on ART by 2022, with HIV-associated deaths averted by up to 69% since the peak in 2004 [ 1 ]. Despite the improved access to ART, 630,000 global HIV-associated deaths were reported in 2022 with three in five deaths occurring in the African region [ 1 ]. HIV-associated mortality amongst hospitalized PLHIV in Africa is high, ranging between 13.6 and 38% [ 2 , 3 , 4 , 5 ]. Factors such as undiagnosed HIV status [ 6 ], low CD4 + cell counts [ 7 , 8 ], tuberculosis [ 9 ], and co-infections [ 2 , 3 , 4 ] are among the common predictors of mortality among hospitalized PLHIV.

Uganda has made significant strides towards achieving the 95-95-95 HIV care cascade targets with more than 90% of PLHIV aware of their HIV status and 85% accessing ART [ 10 ]. However, despite these gains, an estimated 54,000 new HIV infections and 17,000 HIV-associated deaths were reported in 2022 [ 10 ]. There is a paucity of data on the factors associated with mortality among hospitalized PLHIV in Uganda. A recent study found that HIV disease was one of the leading causes of mortality among patients admitted at a major tertiary hospital in Uganda but did not explore the factors that predicted mortality in the HIV subpopulation [ 11 ]. An earlier study done before the test-and-treat era found an association between opportunistic infections and mortality among hospitalized PLHIV [ 12 ].

In March 2020, Makerere University Joint AIDS Program (MJAP) and Kiruddu National Referral Hospital (KNRH) partnered with the Infectious Diseases Institute (IDI) to establish a pilot program to support care for hospitalized PLHIV at KNRH. This was part of the Kampala HIV project run by the IDI with funding from the President’s Emergency Plan for AIDS Relief (PEPFAR), through the Centres for Disease Control and Prevention (CDC) [ 13 ]. The program aimed to reduce HIV-associated morbidity and mortality through the provision of extended support services for hospitalized PLHIV. The services offered included targeted HIV screening at the emergency department, diagnosis and treatment of opportunistic infections (OIs) and comorbidities, ART initiation and support counselling services, post-discharge counselling, and post-discharge linkage to care, as well as training of KNRH healthcare providers in managing HIV disease. These activities were based on the 2020 Ugandan National HIV Care and Treatment guidelines [ 14 ] and were integrated into the routine hospital procedures of KNRH. We analyzed the in-hospital mortality rate and predicting clinical and demographic factors among PLHIV admitted to KNRH between March 2020 and March 2023.

Study design and setting

This cross-sectional study was conducted at KNRH, a national referral hospital with a bed capacity of 200 and serves more than 100,000 patients annually [ 15 ] The hospital offers a range of medical and diagnostic services to the catchment population and established the first elaborate support program for hospitalized PLHIV in the country [ 13 , 15 ].

Study population

The study population included all identified PLHIV aged ≥ 12 years who were hospitalized at KNRH between March 2020 and March 2023.

Sampling methods

All identified PLHIV admitted at KNRH between March 2020 and March 2023 were included in the study.

Study procedure

We extracted, cleaned and entered de-identified data of patient health records into a password protected backed-up electronic Excel database. The clinical endpoint was the patient’s vital status “Alive” or “Dead” outcome at discharge/transfer from KNRH. Data on independent social-demographic variables included age, sex and distance of patients’ home addresses from KNRH estimated in kilometres (km) using arbitrary cut-offs of < 10 km, 10–20 km and > 20 km. clinical data variables included CD4 + cell counts, viral load, ART history (naïve or experienced at admission, adherence counselling), clinical diagnoses and function assessment scores (using the Eastern Cooperative Oncology Group (ECOG) score). ECOG scores of 3–4 were categorized as “poor function status”, indicating severe function impairment, while ECOG scores of 1–2 were categorized as “good function status” indicating mild to moderate function impairment).

Clinical diagnoses were categorized as “opportunistic infections” or “comorbidities.” The opportunistic infections (OIs) included TB, Cryptococcal disease, candidiasis, toxoplasmosis, and Kaposi sarcoma. The comorbidities included cardiovascular diseases, diabetes mellitus, kidney disease, liver disease, neurologic disorders, chronic lung diseases, cancers, anaemia and other co-infections (excluding OIs). Table  1 summarizes the definitions and categorization of the clinical diagnoses.

ART status at admission was categorized as “Active,” “Interrupted” or “Naïve” as guided by the 2020 National treatment guidelines. Patients who had never received ART (whether newly diagnosed or previously known HIV) were categorized as “ART Naïve” while a patient who interrupted ART ≥ three months before the current hospital admission was considered to have “Interrupted ART”. Patients were considered “Active on ART” if they or their attendants reported consistent use of ART regardless of duration at admission or if they had interrupted ART for a period < three months before admission.

Statistical analysis

The primary outcome, mortality, was determined as the number of PLHIV who died divided by the total number of PLHIV that were admitted. Univariate analysis was performed to summarize the baseline characteristics of the study participants. For bivariate analysis, we used the Pearson chi-square test to determine the association between mortality and patients’ baseline characteristics. Variables with a p value greater than an arbitrary value of 0.25 were excluded from the multivariate analysis.

At multivariate analysis, adjusted odds ratios (AOR) from a multivariate binary logistic regression model were used with two-sided p values < 0.05 considered statistically significant. We performed analysis of variance between independent variables and excluded all variables which were highly correlated with each other, to control for type II errors. Multicollinearity was assessed using the Variance Inflation Factor (VIF) of dummy variables and the mean VIF was 1.36. Goodness of fit was performed after running the binary logistic regression model and was found to be correctly specified at a p value of 0.045. The model assumed characteristics of independence of independent variables, and non-inflated standard errors. Data analysis was done using Stata/MP 14 (Stata Corp LLC, Texas, USA).

Ethical approval

Ethical approval was obtained from the Makerere University, College of Health Sciences, School of Public Health, research ethics committee under Reference MakSPH-REC710 and reference HS553ES under the Uganda National Council for Science and Technology. A waiver for informed consent was obtained since we sought to use only already existing routinely collected, de-identified program data requiring no contact with participants.

Baseline characteristics

Of the 30,537 persons admitted at KNRH from March 2020 to March 2023, 5,827 (19.1%) PLHIV were identified, of whom 3,293 (56.5%) were females. The median age was 39 years (IQR 31–49 years), and the median duration of hospitalization was 5 days (IQR 2–10 days). CD4 + cell count was documented among 3,715 (63.8%) hospitalized PLHIV of whom 2,271 (38.97%) had CD4 + cell count ≤ 200 cells/µL. The median CD4 + cell count was 109 cells/µL (IQR 25–343 cells/µl).

A total of 4,854 (83.3%) PLHIV had initiated ART before admission of whom 3,710 (63.7%) were active on their treatment while 1,144 (19.6%) had interrupted ART longer than three months; 973 (16.7%) were ART naïve. A poor ECOG function assessment (ECOG score 3–4) was observed in 2,225 (38.2%) of hospitalized PLHIV. Table  2 summarizes the baseline characteristics of the patients at admission.

Co-infections and comorbidities

The OIs included TB (1954, 33.53%), Cryptococcal disease (739, 12.68%), candidiasis (443, 7.6%), toxoplasmosis (142, 2.44%) and Kaposi sarcoma (124, 2.13%). Other comorbid diagnoses included co-infections (1,367, 23.46%), cardiovascular disease (975, 16.7%), severe malnutrition (807, 13.9%), anaemia (646, 11.1%) and kidney disease (514, 8.82%). (Table  2 ).

In-Hospital mortality

A total of 4,303 (73.85%) PLHIV were discharged from the hospital with a median duration of hospitalization of 6 days (IQR 3–11 days), while 1,524 (26.15%) died with a median time to death of 3 days (IQR 1–7 days).

Factors Associated with HIV Mortality

At bivariate analysis, the factors that had a statistically significant association with mortality included age, sex, distance between home address and KNRH, readmission status, ART status, CD4 + cell counts, function assessment, COVID-19, cardiovascular disease, kidney disease, liver disease, anaemia, co-infections, malnutrition, diabetes mellitus, neurologic disorders and chronic lung disease (Table  2 ).

At multivariate analysis, factors that predicted mortality included function impairment, CD4 + count ≤ 200 cells/µL, undocumented CD4 + status, address > 20 km from hospital, ART interruption, COVID-19, liver disease and co-infections. Factors that were protective of mortality included hospital readmission, chronic lung disease and neurologic disorders (Table  3 ). Malnutrition, kidney disease, cardiovascular disease, anaemia and age were excluded from the multivariate analysis due to high multicollinearity.

In this study, we assessed in-hospital mortality and associated factors among hospitalized PLHIV in Uganda. In this young population with a median age of 39 years, the in-hospital mortality was 26%. Almost two-fifths of the hospitalized PLHIV had advanced HIV disease (CD4 + cell count ≤ 200 cells/µL) and more than a third were not on ART at the time of admission. Factors which predicted in-hospital mortality included ART interruption, CD4 + cell counts ≤ 200 cells/µL, undocumented CD4 + cell counts, function impairment, co-infections, liver disease and long distance from the hospital.

The high mortality observed in our study is of significant concern as over a quarter of the hospitalized PLHIV succumbed to their illness in an era of Universal Test and Treat [ 16 ]. This observation is similar to the high in-hospital mortality reported in previous studies, ranging between 14 and 38% across various African settings [ 2 , 3 , 4 ]. Notably, we observed that most of the deaths occurred within a week of hospitalization which echoes findings from a study in Sierra Leone [ 3 ]. Our study site being a tertiary-level health facility raises concerns over patient-related or health system-related factors that contribute to poor healthcare-seeking behaviour and late hospital presentation. The high proportion of hospitalized PLHIV presenting with advanced HIV disease (39%) and significant function impairment (38%) in our study suggests a delayed or late presentation for healthcare [ 17 , 18 , 19 ]. Health system barriers such as long distance to the hospital could be another contributing factor to poor outcomes among hospitalized PLHIV. We observed that PLHIV who lived > 20 km from the hospital had higher odds of death compared to those who stayed < 10 km from the hospital. This observation agrees with other studies that identified long distance to a health facility as a barrier to accessing healthcare, potentially increasing the risk of mortality [ 20 ]. Use of patient-centred differentiated care approaches that take HIV services closer to the PLHIV may help address such barriers [ 21 ]. Encouraging early health-seeking behaviour among PLHIV could also improve hospital outcomes.

Of note, more than a third of the hospitalized PLHIV in our study were not on ART (Naïve or interrupted) at the time of admission. We observed that those who had interrupted their ART had 1.3 times the odds of dying during hospitalization compared to those who were active on ART. Our observations agree with other community-based studies that showed that up to a third of PLHIV who disengaged from HIV care were at a higher risk of mortality [ 22 , 23 , 24 , 25 ]. Since suboptimal ART coverage is associated with poor survival outcomes, there is an urgent need to understand and address the factors that contribute to patient disengagement from HIV care. Examples of factors that propagate patient disengagement from care include transportation costs [ 20 ], food insecurity [ 26 ] and the professional behaviour of health workers [ 27 ]. Efforts to retain PLHIV at risk of attrition from lifelong ART must be prioritized to optimize outcomes [ 28 ].

PLHIV who had poor function status at admission had more than seven times the odds of dying during hospitalization compared to those with good function status. Studies from Uganda and Ethiopia using different function assessment tools also revealed associations between poor function status and mortality among hospitalized PLHIV [ 12 , 29 ]. In other studies, poor function status predicted late presentation of HIV disease [ 18 , 19 ]. This evidence suggests that assessing functional status among hospitalized PLHIV is crucial for predicting mortality, allowing for identification of high-risk patients who may benefit from rapid interventions to improve outcomes.

PLHIV who had low CD4 + cell counts ≤ 200 cells/µL had 1.68 times the odds of dying during hospitalization compared to those with higher CD4 cell counts. These findings agree with studies from various settings emphasizing the increased risk of mortality associated with low CD4 + cell counts [ 7 , 8 ], thus underscoring the importance of enhanced CD4 + screening among hospitalized PLHIV. In addition, PLHIV who did not have a documented CD4 + cell count had double the odds of death during hospitalization compared to those with high CD4 + cell counts. While reasons for this observation are not immediately clear, we postulate that increased mortality is linked to the missed opportunities to screen and diagnose important OIs. A recent national survey found suboptimal levels of CD4 + testing among PLHIV, which translated into a missed opportunity to screen 80% of potential TB and Cryptococcal disease patients [ 30 ]. Thus, screening and documentation of CD4 + cell counts could be useful amongst hospitalized PLHIV to improve hospital outcomes.

Tuberculosis, Cryptococcal disease and co-infections were highly prevalent in our study. However, both TB and Cryptococcal disease did not predict mortality despite being known predictors of mortality among hospitalized HIV patients [ 2 , 3 , 31 , 32 ]. Plausible explanations for this observation might be due to, (a) the declining incidence of these infections underscoring the vast experience gained in investigations and treatment of OIs [ 5 ]; (b) the availability of improved rapid diagnostics such as the lateral flow antigen tests which facilitate early diagnosis and treatment of these infections [ 33 , 34 , 35 ] or (c) the protective effect of prophylactic treatment such as isoniazid to reduce the incidence of opportunistic infections [ 36 , 37 ]. These findings re-emphasize the importance of screening, prevention and treatment of opportunistic infections to optimize outcomes among hospitalized PLHIV.

Unlike opportunistic infections, PLHIV who were diagnosed with co-infections or COVID-19 had increased odds of mortality during hospitalization. Several studies agree with these observations where co-infections [ 3 , 4 ] and COVID-19 infection [ 38 ] were associated with increased risk of mortality amongst the hospitalized PLHIV. These findings suggest that co-infections remain an important cause of mortality among hospitalized PLHIV, emphasizing the need for enhanced screening and treatment of such among hospitalized PLHIV.

Hospitalized PLHIV who were diagnosed with liver disease in our study had 1.77 times the odds of dying compared to those without liver disease. These findings agree with other studies that reveal a growing burden of liver disease that predisposes to increased risk of mortality among PLHIV [ 39 , 40 , 41 ]. Among the common presentations of liver disease among African PLHIV include drug induced liver injury from anti-TB or ART [ 42 , 43 ], chronic viral infections [ 44 , 45 ], liver fibrosis [ 46 , 47 ], and alcoholic liver disease [ 46 , 47 ]. Screening measures should be enhanced to enable early detection and treatment of high-risk PLHIV who develop liver disease manifestations particularly those on anti-TB medications (due to risk of drug-induced liver injury) or those with viral hepatitis co-infections.

Hospitalized PLHIV who were diagnosed with chronic lung disease had reduced odds of mortality. While we interpret this finding with a degree of uncertainty, existing literature suggests an increasing burden of chronic lung diseases associated with HIV disease such as post-TB lung disease [ 48 , 49 , 50 , 51 ], chronic obstructive airway disease [ 52 , 53 , 54 ], bronchiectasis [ 55 , 56 ], asthma exacerbations [ 57 ] and altered respiratory microbiome predisposing to chronic airway inflammation [ 58 , 59 ]. However, data on the survival outcomes of PLHIV diagnosed with chronic lung diseases is scarce, with some studies suggesting an increased risk of mortality with HIV disease [ 57 , 59 , 60 ], contrary to our study findings. Further research to better understand the interaction between HIV disease and chronic lung diseases is warranted.

Likewise, hospitalized PLHIV who were diagnosed with neurologic disorders also had reduced odds of mortality in our study. This observation is also not fully understood but one plausible explanation is the fact that such patients are often transferred to another hospital that provides specialized care for neurologic and mental disorders. These masked the true interactions between HIV disease and the comorbidities observed in our study site. Furthermore, the low prevalence of neurologic disorders in our study could have contributed to the masked interaction with HIV disease. Neurologic disorders have varied manifestations in HIV disease such as HIV-associated cognitive disorders [ 61 , 62 ], seizure disorders [ 63 ] and major depressive disorders [ 64 ]. Some studies suggest an increased risk of mortality associated with neurologic disorders amongst PLHIV [ 65 ]. These complexities highlight the challenges in the care for PLHIV diagnosed with neurologic disorders in resource poor settings but warrant further research to understand the magnitude and interaction with HIV disease.

PLHIV who were readmitted to hospital also had reduced odds of mortality compared to the new admissions. About one in ten PLHIV in our study were readmitted in our study, a finding slightly lower than recent estimates of 18.8% [ 66 ]. The protective effect of hospital readmission in our study is not fully understood and equally warrants further research into understanding this interaction.

Study limitations

In this large single site study, we identified factors that predicted in-hospital mortality among hospitalized PLHIV in Uganda. However, we acknowledge a few limitations inherent to the study. One, we lacked autopsy reports to confirm the causes of death among the patients, thus potentially missing some key clinical diagnoses [ 67 ]. The causes of death were inferred from the clinical diagnoses since autopsies are not routinely done at the hospital due to multiple reasons such as refusal by family members [ 68 , 69 ]. Secondly, the lack of a control group (e.g. HIV negative subpopulation) limited further analysis and interpretation of the results. Data from an in-hospital HIV support program was used to inform the study findings. Thirdly, the retrospective nature of the study meant some variables could not be assessed such as cognitive function in neurologic disorders. In addition, some variables demonstrated high correlation with others further complicating interpretation of the findings. High multicollinearity was overcome by excluding such variables at multivariate analysis. Fourthly, the lack of a standardized categorization system for clinical diagnoses meant some variables could have been misdiagnosed or misclassified especially for those with similar presentations such as immune reconstitution inflammatory syndromes and infections. Lastly, our findings are limited to a single tertiary-level hospital which may be skewed towards patients requiring super-specialized healthcare services. The findings may not be generalized to the majority who access healthcare from lower-level health facilities [ 70 ]. Despite these limitations, the study findings provide valuable lessons for improving outcomes for hospitalized PLHIV.

One in every four PLHIV is at risk of dying following hospitalization in Uganda. The factors that predicted mortality amongst the hospitalized PLHIV were interruption of antiretroviral therapy, low CD4 + cell counts ≤ 200 cells/µL, unknown CD4 + cell count status, function impairment, co-infections, COVID-19 and liver disease.

There is a need for targeted multisectoral interventions to optimize the care and treatment of hospitalized PLHIV. At an individual level, enhanced HIV testing, early initiation and retention on ART should be prioritized to leverage the benefits of lifelong ART, as well as addressing barriers that hinder timely access to healthcare. At the hospital level, strengthening screening protocols to identify most-at-risk PLHIV such as those with advanced HIV disease or unknown CD4 + cell counts, or function impairment could improve survival through timely interventions such as screening and treatment of co-infections and comorbidities. Patient education on disease prevention particularly regarding the non-communicable diseases such as liver disease, may also help avert poor outcomes following hospitalization. Standardizing health information systems by use of standardized classification tools for clinical diagnoses could improve accurate data interpretation and sharing with relevant stakeholders and health policymakers to better understand disease trends and appropriately allocate resources to respond to emerging healthcare threats.

Data availability

The datasets generated and/or analysed during the current study are not publicly available due to the privacy and confidentiality of hospital records but are available from the corresponding author on reasonable request.

Abbreviations

Adjusted odds ratio

Antiretroviral therapy

Cluster of differentiation four positive

Centre for Disease Prevention and Control

Central nervous system

19–Coronavirus disease 2019

Cryptococcal Antigen

Eastern Cooperative Oncology Group

Human immunodeficiency virus

Inter quartile range

Kiruddu National Referral Hospital

Lipoarabinomannan antigen

Makerere University Joint AIDS Program

Ministry of Health Uganda

Opportunistic Infections

President’s Emergency Plan for AIDS Relief

People living with HIV

Tuberculosis

UNAIDS, Global HIV. & AIDS statistics — Fact sheet| UNAIDS [Internet]. 2022 [cited 2022 Oct 21]. Available from: https://www.unaids.org/en/resources/fact-sheet .

Laher AE, Paruk F, Venter WDF, Ayeni OA, Richards GA. Predictors of in-hospital mortality among HIV-positive patients presenting with an acute illness to the emergency department. HIV Med. 2021;22(7):557–66.

Article   CAS   PubMed   Google Scholar  

Lakoh S, Jiba DF, Kanu JE, Poveda E, Salgado-Barreira A, Sahr F et al. Causes of hospitalization and predictors of HIV-associated mortality at the main referral hospital in Sierra Leone: a prospective study. BMC Public Health. 2019;19(1).

Lewden C, Drabo YJ, Zannou DM, Maiga MY, Minta DK, Sow PS et al. Disease patterns and causes of death of hospitalized HIV-positive adults in West Africa: a multicountry survey in the antiretroviral treatment era. J Int AIDS Soc. 2014;17(1).

Barak T, Neo DT, Tapela N, Mophuthegi P, Zash R, Kalenga K et al. HIV-associated morbidity and mortality in a setting of high ART coverage: prospective surveillance results from a district hospital in Botswana. J Int AIDS Soc. 2019;22(12).

Moodley Y. The impact of an unknown HIV serostatus on inpatient mortality. Pan Afr Med J [Internet]. 2017 Nov 30 [cited 2021 Dec 31];28. Available from: https://pubmed.ncbi.nlm.nih.gov/29942417/ .

Hogg RS, Yip B, Chan KJ, Wood E, Craib KJP, O’Shaughnessy MV et al. Rates of disease progression by baseline CD4 cell count and viral load after initiating triple-drug therapy. JAMA [Internet]. 2001 Nov 28 [cited 2022 May 14];286(20):2568–77. Available from: https://pubmed.ncbi.nlm.nih.gov/11722271/ .

Gunda DW, Nkandala I, Kilonzo SB, Kilangi BB, Mpondo BC. Prevalence and risk factors of mortality among adult HIV patients initiating ART in Rural setting of HIV Care and Treatment Services in North Western Tanzania: a retrospective cohort study. J Sex Transm Dis. 2017;2017:1–8.

Article   Google Scholar  

Ford N, Matteelli A, Shubber Z, Hermans S, Meintjes G, Grinsztejn B et al. TB as a cause of hospitalization and in-hospital mortality among people living with HIV worldwide: a systematic review and meta-analysis. J Int AIDS Soc [Internet]. 2016 Jan 12 [cited 2021 Dec 31];19(1). Available from: https://pubmed.ncbi.nlm.nih.gov/26765347/ .

UNAIDS. Uganda| UNAIDS [Internet]. 2022 [cited 2022 Oct 21]. Available from: https://www.unaids.org/en/regionscountries/countries/uganda .

Kalyesubula Id R, Id TR, Andia-Biraro I, Alupo P, Kimuli I, Nabirye S et al. Trends of admissions and case fatality rates among medical in-patients at a tertiary hospital in Uganda; A four-year retrospective study. 2019; https://doi.org/10.1371/journal.pone.0216060 .

Namutebi AMN, Kamya MRK, Byakika-Kibwika P. Causes and outcome of hospitalization among HIV-infected adults receiving antiretroviral therapy in Mulago hospital, Uganda. Afr Health Sci [Internet]. 2014 Jan 30 [cited 2022 Jan 19];13(4):977–85. Available from: https://www.ajol.info/index.php/ahs/article/view/100392 .

Makerere University Joint AIDS Program. Welcome To Makerere Joint Aids Program [Internet]. 2022 [cited 2022 Jan 1]. Available from: https://mjap.mak.ac.ug/ .

Ministry of Health Uganda; MINISTRY OF HEALTH CONSOLIDATED GUIDELINES FOR THE PREVENTION AND TREATMENT OF HIV AND AIDS IN UGANDA 2020 [Internet]. 2020. Available from: https://differentiatedservicedelivery.org/Portals/0/adam/Content/HvpzRP5yUUSdpCe2m0KMdQ/ File/Uganda_Consolidated HIV and AIDS Guidelines 2020 June 30th.pdf.

Ministry of Health Uganda; Kiruddu Referral Hospital [Internet]. 2022 [cited 2022 Jan 1]. Available from: https://www.kiruddu.hosp.go.ug/ .

World Health Organization.; Consolidated guidelines on HIV prevention, testing, treatment, service delivery and monitoring: recommendations for a public health approach. 2021 [cited 2022 Jan 19];131. Available from: https://www.who.int/publications/i/item/9789240031593 .

Haas AD, Radin E, Birhanu S, Low AJ, Saito S, Sachathep K et al. Prevalence of and factors associated with late diagnosis of HIV in Malawi, Zambia, and Zimbabwe: Results from population-based nationally representative surveys. PLOS global public health [Internet]. 2022 Feb 22 [cited 2023 Jul 23];2(2):e0000080. Available from: https://pubmed.ncbi.nlm.nih.gov/36962254/ .

Gesesew H, Tsehaineh B, Massa D, Tesfay A, Kahsay H, Mwanri L. The prevalence and associated factors for delayed presentation for HIV care among tuberculosis/HIV co-infected patients in Southwest Ethiopia: a retrospective observational cohort. Infect Dis Poverty [Internet]. 2016 Nov 2 [cited 2022 Oct 25];5(1). Available from: https://pubmed.ncbi.nlm.nih.gov/27802839/ .

Assen A, Molla F, Wondimu A, Abrha S, Melkam W, Tadesse E et al. Late presentation for diagnosis of HIV infection among HIV positive patients in South Tigray Zone, Ethiopia. BMC Public Health [Internet]. 2016 Jul 12 [cited 2022 Oct 25];16(1). Available from: https://pubmed.ncbi.nlm.nih.gov/27405542/ .

Tuller DM, Bangsberg DR, Senkungu J, Ware NC, Emenyonu N, Weiser SD. Transportation costs impede sustained adherence and access to HAART in a clinic population in southwestern Uganda: a qualitative study. AIDS Behav [Internet]. 2010 Aug [cited 2023 Oct 27];14(4):778–84. Available from: https://pubmed.ncbi.nlm.nih.gov/19283464/ .

Zakumumpa H, Kwiringira J, Katureebe C, Spicer N. Understanding Uganda’s early adoption of novel differentiated HIV treatment services: a qualitative exploration of drivers of policy uptake. BMC Health Serv Res [Internet]. 2023 Dec 1 [cited 2024 Jan 17];23(1):1–14. Available from: https://bmchealthservres.biomedcentral.com/articles/ https://doi.org/10.1186/s12913-023-09313-x .

Anderegg N, Hector J, Jefferys LF, Burgos-Soto J, Hobbins MA, Ehmer J, et al. Loss to follow-up correction increased mortality estimates in HIV-positive people on antiretroviral therapy in Mozambique. J Clin Epidemiol. 2020;128:83–92.

Article   PubMed   PubMed Central   Google Scholar  

Tymejczyk O, Vo Q, Kulkarni SG, Antelman G, Boshe J, Reidy W, et al. Tracing-corrected estimates of disengagement from HIV care and mortality among patients enrolling in HIV care without overt immunosuppression in Tanzania. AIDS Care. 2021;33(1):47–53.

Article   PubMed   Google Scholar  

Wekesa P, McLigeyo A, Owuor K, Mwangi J, Nganga E, Masamaro K. Factors associated with 36-month loss to follow-up and mortality outcomes among HIV-infected adults on antiretroviral therapy in Central Kenya. BMC Public Health. 2020;20(1).

Burkey MD, Weiser SD, Fehmie D, Alamo-Talisuna S, Sunday P, Nannyunja J, et al. Socioeconomic determinants of mortality in HIV: evidence from a clinical cohort in Uganda. J Acquir Immune Defic Syndr. 2014;66(1):41–7.

Hardon AP, Akurut D, Comoro C, Ekezie C, Irunde HF, Gerrits T et al. Hunger, waiting time and transport costs: time to confront challenges to ART adherence in Africa. AIDS Care [Internet]. 2007 [cited 2023 Oct 27];19(5):658–65. Available from: https://pubmed.ncbi.nlm.nih.gov/17505927/ .

Ware NC, Wyatt MA, Geng EH, Kaaya SF, Agbaji OO, Muyindike WR et al. Toward an Understanding of Disengagement from HIV Treatment and Care in Sub-Saharan Africa: A Qualitative Study. PLoS Med [Internet]. 2013 Jan [cited 2023 Oct 27];10(1). Available from: /pmc/articles/PMC3541407/.

UNAIDS. 2020. [cited 2022 Jan 19]. 2025 AIDS TARGETS - UNAIDS. Available from: https://aidstargets2025.unaids.org/ .

Kebede A, Tessema F, Bekele G, Kura Z, Merga H. Epidemiology of survival pattern and its predictors among HIV positive patients on highly active antiretroviral therapy in Southern Ethiopia public health facilities: a retrospective cohort study. AIDS Res Ther [Internet]. 2020 Aug 5 [cited 2022 Oct 25];17(1). Available from: https://pubmed.ncbi.nlm.nih.gov/32758247/ .

Meya DB, Tugume L, Nabitaka V, Namuwenge P, Phiri S, Oladele R et al. Establishing targets for advanced HIV disease: a call to action. South Afr J HIV Med. 2021;22(1).

Ford N, Matteelli A, Shubber Z, Hermans S, Meintjes G, Grinsztejn B et al. TB as a cause of hospitalization and in-hospital mortality among people living with HIV worldwide: a systematic review and meta-analysis. J Int AIDS Soc. 2016;19(1).

Saavedra A, Campinha-Bacote N, Hajjar M, Kenu E, Gillani FS, Obo-Akwa A et al. Causes of death and factors associated with early mortality of HIV-infected adults admitted to Korle-Bu Teaching Hospital. Pan Afr Med J. 2017;27.

Nathavitharana RR, Lederer P, Chaplin M, Bjerrum S, Steingart KR, Shah M. Impact of diagnostic strategies for tuberculosis using lateral flow urine lipoarabinomannan assay in people living with HIV. Cochrane Database Syst Rev. 2021;8(8).

Ricks S, Denkinger CM, Schumacher SG, Hallett TB, Arinaminpathy N. The potential impact of urine-LAM diagnostics on tuberculosis incidence and mortality: a modelling analysis. PLoS Med. 2020;17(12).

Gupta-Wright A, Corbett EL, Wilson D, Van Oosterhout JJ, Dheda K, Huerga H et al. Risk score for predicting mortality including urine lipoarabinomannan detection in hospital inpatients with HIV-associated tuberculosis in sub-Saharan Africa: Derivation and external validation cohort study. PLoS Med [Internet]. 2019 [cited 2023 Oct 28];16(4). Available from: https://pubmed.ncbi.nlm.nih.gov/30951533/ .

Zar HJ, Cotton MF, Strauss S, Karpakis J, Hussey G, Schaaf S et al. Effect of isoniazid prophylaxis on mortality and incidence of tuberculosis in children with HIV: randomised controlled trial. BMJ [Internet]. 2007 Jan 20 [cited 2023 Oct 27];334(7585):136–9. Available from: https://pubmed.ncbi.nlm.nih.gov/17085459/ .

Briggs MA, Emerson C, Modi S, Taylor NK, Date A. Use of isoniazid preventive therapy for tuberculosis prophylaxis among people living with HIV/AIDS: a review of the literature. J Acquir Immune Defic Syndr [Internet]. 2015 Apr 15 [cited 2023 Oct 27];68 Suppl 3(Suppl 3):S297–305. Available from: https://pubmed.ncbi.nlm.nih.gov/25768869/ .

Risk Factors for Coronavirus Disease. 2019 (COVID-19) Death in a Population Cohort Study from the Western Cape Province, South Africa. Clin Infect Dis. 2021;73(7):e2005–15.

Puoti M, Spinetti A, Ghezzi A, Donato F, Zaltron S, Putzolu V et al. Mortality for liver disease in patients with HIV infection: a cohort study. J Acquir Immune Defic Syndr [Internet]. 2000 Jul 1 [cited 2022 Jan 25];24(3):211–7. Available from: https://pubmed.ncbi.nlm.nih.gov/10969344/ .

Smith CJ, Ryom L, Weber R, Morlat P, Pradier C, Reiss P et al. Trends in underlying causes of death in people with HIV from 1999 to 2011 (D:A:D): a multicohort collaboration. Lancet [Internet]. 2014 [cited 2022 Jan 25];384(9939):241–8. Available from: https://pubmed.ncbi.nlm.nih.gov/25042234/ .

Lieveld FI, Smit C, Richter C, van Erpecum KJ, Spanier BWM, Gisolf EH et al. Liver decompensation in HIV/Hepatitis B coinfection in the combination antiretroviral therapy era does not seem increased compared to hepatitis B mono-infection. Liver Int [Internet]. 2019 Mar 1 [cited 2022 Jan 25];39(3):470–83. Available from: https://pubmed.ncbi.nlm.nih.gov/30411848/ .

Cainelli F, Vento S. Liver disease in patients with HIV in sub-Saharan Africa. Lancet HIV [Internet]. 2015 Oct 1 [cited 2022 Jan 21];2(10):e412–3. Available from: http://www.thelancet.com/article/S2352301815001794/fulltext .

Schutz C, Ismail Z, Proxenos CJ, Marais S, Burton R, Kenyon C et al. Burden of antituberculosis and antiretroviral drug-induced liver injury at a secondary hospital in South Africa. S Afr Med J [Internet]. 2012 [cited 2022 Jan 25];102(6):506–11. Available from: https://pubmed.ncbi.nlm.nih.gov/22668951/ .

Feld JJ, Ocama P, Ronald A. The liver in HIV in Africa. Antivir Ther [Internet]. 2005 [cited 2022 Jan 21];10(8):953–65. Available from: https://pubmed.ncbi.nlm.nih.gov/16430201/ .

Stabinski L, O’Connor S, Barnhart M, Kahn RJ, Hamm TE. Prevalence of HIV and hepatitis B virus co-infection in sub-Saharan Africa and the potential impact and program feasibility of hepatitis B surface antigen screening in resource-limited settings. J Acquir Immune Defic Syndr [Internet]. 2015 Apr 15 [cited 2022 Jan 25];68 Suppl 3:S274–85. Available from: https://pubmed.ncbi.nlm.nih.gov/25768867/ .

Stabinski L, Reynolds SJ, Ocama P, Laeyendecker O, Ndyanabo A, Kiggundu V et al. High prevalence of liver fibrosis associated with HIV infection: a study in rural Rakai, Uganda. Antivir Ther [Internet]. 2011 [cited 2024 Jan 13];16(3):405–11. Available from: https://pubmed.ncbi.nlm.nih.gov/21555823/ .

Jaquet A, Wandeler G, Nouaman M, Ekouevi DK, Tine J, Patassi A et al. Alcohol use, viral hepatitis and liver fibrosis among HIV-positive persons in West Africa: a cross-sectional study. J Int AIDS Soc [Internet]. 2017 Feb 17 [cited 2022 Jan 21];19(1). Available from: https://pubmed.ncbi.nlm.nih.gov/28362065/ .

Tomeny EM, Nightingale R, Chinoko B, Nikolaidis GF, Madan JJ, Worrall E et al. TB morbidity estimates overlook the contribution of post-TB disability: evidence from urban Malawi. BMJ Glob Health [Internet]. 2022 May 3 [cited 2023 Oct 28];7(5). Available from: https://pubmed.ncbi.nlm.nih.gov/35606014/ .

Mkoko P, Naidoo S, Mbanga LC, Nomvete F, Muloiwa R, Dlamini S. Chronic lung disease and a history of tuberculosis (post-tuberculosis lung disease): Clinical features and in-hospital outcomes in a resource-limited setting with a high HIV burden. S Afr Med J [Internet]. 2019 Mar 1 [cited 2023 Oct 28];109(3):169–73. Available from: https://pubmed.ncbi.nlm.nih.gov/30834873/ .

Menzies NA, Quaife M, Allwood BW, Byrne AL, Coussens AK, Harries AD et al. Lifetime burden of disease due to incident tuberculosis: a global reappraisal including post-tuberculosis sequelae. Lancet Glob Health [Internet]. 2021 Dec 1 [cited 2023 Oct 28];9(12):e1679–87. Available from: https://pubmed.ncbi.nlm.nih.gov/34798027/ .

Meghji J, Lesosky M, Joekes E, Banda P, Rylance J, Gordon S et al. Patient outcomes associated with post-tuberculosis lung damage in Malawi: a prospective cohort study. Thorax [Internet]. 2020 Mar 1 [cited 2023 Oct 28];75(3):269–78. Available from: https://pubmed.ncbi.nlm.nih.gov/32102951/ .

Ddungu A, Semitala FC, Castelnuovo B, Sekaggya-Wiltshire C, Worodria W, Kirenga BJ. Chronic obstructive pulmonary disease prevalence and associated factors in an urban HIV clinic in a low income country. PLoS One [Internet]. 2021 Aug 1 [cited 2023 Oct 28];16(8). Available from: https://pubmed.ncbi.nlm.nih.gov/34388209/ .

Drummond MB, Kunisaki KM, Huang L. Obstructive Lung Diseases in HIV: A Clinical Review and Identification of Key Future Research Needs. Semin Respir Crit Care Med [Internet]. 2016 Apr 1 [cited 2023 Oct 28];37(2):277–88. Available from: https://pubmed.ncbi.nlm.nih.gov/26974304/ .

Kayongo A, Wosu AC, Naz T, Nassali F, Kalyesubula R, Kirenga B et al. Chronic obstructive pulmonary disease prevalence and associated factors in a setting of well-controlled HIV, a cross-sectional study. COPD [Internet]. 2020 May 3 [cited 2023 Oct 28];17(3):297. Available from: /pmc/articles/PMC8126339/.

Konstantinidis I, Crothers K, Kunisaki KM, Drummond MB, Benfield T, Zar HJ et al. HIV-associated lung disease. Nat Rev Dis Primers [Internet]. 2023 Dec 1 [cited 2023 Oct 28];9(1). Available from: https://pubmed.ncbi.nlm.nih.gov/37500684/ .

Attia EF, Miller RF, Ferrand RA. Bronchiectasis and other chronic lung diseases in adolescents living with HIV. Curr Opin Infect Dis [Internet]. 2017 [cited 2023 Oct 28];30(1):21–30. Available from: https://pubmed.ncbi.nlm.nih.gov/27753690/ .

Ibrahim AO, Aremu SK, Afolabi BA, Ajani GO, Kolawole FT, Oguntoye OA. Acute severe asthma and its predictors of mortality in rural Southwestern Nigeria: a-five year retrospective observational study. Chron Respir Dis [Internet]. 2023 Jan 1 [cited 2023 Oct 28];20. Available from: https://pubmed.ncbi.nlm.nih.gov/36652901/ .

Kayongo A, Bartolomaeus TUP, Birkner T, Markó L, Löber U, Kigozi E et al. Sputum Microbiome and Chronic Obstructive Pulmonary Disease in a Rural Ugandan Cohort of Well-Controlled HIV Infection. Microbiol Spectr [Internet]. 2023 Apr 13 [cited 2023 Oct 28];11(2). Available from: /pmc/articles/PMC10100697/.

Chalmers JD, Goeminne P, Aliberti S, McDonnell MJ, Lonni S, Davidson J et al. The bronchiectasis severity index. An international derivation and validation study. Am J Respir Crit Care Med [Internet]. 2014 Mar 1 [cited 2023 Oct 28];189(5):576–85. Available from: https://pubmed.ncbi.nlm.nih.gov/24328736/ .

Jones RC, Donaldson GC, Chavannes NH, Kida K, Dickson-Spillmann M, Harding S et al. Derivation and validation of a composite index of severity in chronic obstructive pulmonary disease: the DOSE Index. Am J Respir Crit Care Med [Internet]. 2009 Dec 15 [cited 2023 Oct 28];180(12):1189–95. Available from: https://pubmed.ncbi.nlm.nih.gov/19797160/ .

Howlett WP. Neurological disorders in HIV in Africa: a review. Afr Health Sci [Internet]. 2019 [cited 2023 Oct 28];19(2):1953. Available from: /pmc/articles/PMC6794503/.

Mekuriaw B, Belayneh Z, Teshome W, Akalu Y. Prevalence and variability of HIV/AIDS-associated neurocognitive impairments in Africa: a systematic review and meta-analysis. BMC Public Health [Internet]. 2023 Dec 1 [cited 2023 Oct 28];23(1):1–16. Available from: https://bmcpublichealth.biomedcentral.com/articles/ https://doi.org/10.1186/s12889-023-15935-x .

Elafros MA, Johnson BA, Siddiqi OK, Okulicz JF, Sikazwe I, Bositis CM et al. Mortality & recurrent seizure risk after new-onset seizure in HIV-positive Zambian adults. BMC Neurol [Internet]. 2018 Dec 7 [cited 2023 Oct 28];18(1). Available from: https://pubmed.ncbi.nlm.nih.gov/30522451/ .

Lawler K, Mosepele M, Ratcliffe S, Seloilwe E, Steele K, Nthobatsang R et al. Neurocognitive impairment among HIV-positive individuals in Botswana: a pilot study. J Int AIDS Soc [Internet]. 2010 [cited 2023 Oct 28];13(1). Available from: https://pubmed.ncbi.nlm.nih.gov/20406460/ .

Haas AD, Ruffieux Y, van den Heuvel LL, Lund C, Boulle A, Euvrard J et al. Excess mortality associated with mental illness in people living with HIV in Cape Town, South Africa: a cohort study using linked electronic health records. Lancet Glob Health [Internet]. 2020 Oct 1 [cited 2023 Oct 28];8(10):e1326–34. Available from: https://pubmed.ncbi.nlm.nih.gov/32971055/ .

Ford N, Patten G, Rangaraj A, Davies MA, Meintjes G, Ellman T. Outcomes of people living with HIV after hospital discharge: a systematic review and meta-analysis. Lancet HIV [Internet]. 2022 Mar 1 [cited 2023 Oct 28];9(3):e150–9. Available from: https://pubmed.ncbi.nlm.nih.gov/35245507/ .

Cox JA, Lukande RL, Nelson AM, Mayanja-Kizza H, Colebunders R, van Marck E, et al. An autopsy study describing causes of death and comparing clinico-pathological findings among hospitalized patients in Kampala, Uganda. PLoS ONE. 2012;7(3):e33685.

Article   ADS   CAS   PubMed   PubMed Central   Google Scholar  

Namuju OC, Kwizera R, Lukande R, Pastick KA, Taylor JM, Nicol MR et al. Rates of refusal of clinical autopsies among HIV-positive decedents and an overview of autopsies in Uganda. Wellcome Open Res. 2022;6.

Cox JA, Lukande RL, Kateregga A, Mayanja-Kizza H, Manabe YC, Colebunders R. Autopsy acceptance rate and reasons for decline in Mulago Hospital, Kampala, Uganda. Trop Med Int Health. 2011;16(8):1015–8.

Turyamureba M, Yawe B, Oryema JB, Tanzania Journal of Health Research. 2023 [cited 2024 Jan 15]. Health Care Delivery System in Uganda: a review| Tanzania Journal of Health Research. Available from: https://www.ajol.info/index.php/thrb/article/view/231882 .

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Acknowledgements

Sincere appreciation is extended to the administration and staff of Kiruddu National Referral Hospital and Makerere University Joint AIDS Program for implementing the pilot HIV care program to improve the outcomes of hospitalized people living with HIV. Special appreciation and recognition are extended to Atine Edgar, Namugenyi Christabellah, Nabatanzi Cecilia, Kasirye Esther, Kakande Amina, Kabira Deborah, and Adong Florence among others in supporting the program.

The President’s Emergency Plan has supported this research for AIDS Relief (PEPFAR) through the Centre for Diseases Control and Prevention (CDC), under the terms of GH002022.

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Darius Owachi & Charles Kabugo

Makerere University Joint AIDS Program, Kampala, Uganda

Praise Akatukunda, Diana Sarah Nanyanzi, Rogers Katwesigye, Shardrack Wanyina, Martin Muddu, Samuel Kawuma & Fred C. Semitala

Infectious Diseases Institute, Kampala, Uganda

Nelson Kalema

Department of Medicine, Makerere University, Kampala, Uganda

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Contributions

DO, DSN, MM, CK and FCS conceptualized the project. DO, DSN and PA implemented the project and collected the data. DO & PA analysed the data. RK, SW, MM, SK, CK, NK and FCS supervised the implementation of the project and provided a critical review of the manuscript. All authors were major contributors to writing the manuscript. All authors read and approved the final manuscript.

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Correspondence to Darius Owachi .

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Ethical approval was obtained from the Makerere University, College of Health Sciences, School of Public Health research ethics committee under Reference MakSPH-REC 710 and registered the study with the Uganda National Council for Science and Technology under reference HS553ES. The need for informed consent was waived by the Makerere University, College of Health Sciences, School of Public Health research ethics committee since routinely collected program data was used for analysis. Patient identifier information was anonymized to protect patient confidentiality.

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The authors DO, PA, DSN, RK, SW, MM, SK, NK, CK and FCS receive financial remuneration from CDC/PEPFAR as part of employee remuneration benefits. DO & CK have received remuneration benefits from the Government of Uganda. However, the findings and conclusions in this report are those of the authors and do not represent the official position of PEPFAR, CDC Uganda or the Government of Uganda.

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Owachi, D., Akatukunda, P., Nanyanzi, D.S. et al. Mortality and associated factors among people living with HIV admitted at a tertiary-care hospital in Uganda: a cross-sectional study. BMC Infect Dis 24 , 239 (2024). https://doi.org/10.1186/s12879-024-09112-7

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case study of hiv aids in kenya

Kenya launches strategy to combat HIV/AIDS, teenage pregnancies, gender violence

Source: Xinhua

Editor: huaxia

2024-02-25 00:05:15

case study of hiv aids in kenya

NAIROBI, Feb. 24 (Xinhua) -- Kenya's Ministry of Health on Saturday launched a strategy to eliminate the triple threats of HIV/AIDS, teenage pregnancies, and gender-based violence that have reversed progress towards achieving the UN 2030 goals.

Susan Nakhumicha, the cabinet secretary in the Ministry of Health, reaffirmed the government's commitment to leveraging a host of policy and legislative tools to end new HIV infections, adolescent pregnancies, and gender-based violence.

"We have started the journey to eliminate the triple public health crisis of HIV/AIDS, teenage pregnancies, and sexual and gender-based violence in line with our commitment to national and international conventions," Nakhumicha said at the launch that was held in western Kenyan county of Bungoma.

Kenya has 1.5 million people living with HIV and more than 90 percent on life-saving drugs, according to Nakhumicha, who decried the high rate of infections among youth aged 15 years to 24 years. She reiterated the government's commitment to ending HIV/AIDS by 2030 by preventing new infections among high-risk demographics like youth and women alongside expanding access to life-long treatment.

In addition, Nakhumicha said the rollout of the Social Health Insurance Fund will ensure that antiretroviral therapy is affordable to persons living with HIV.

To help curb teenage pregnancies that have also been linked to new HIV infections, Nakhumicha said the government will leverage technology, grassroots campaigns, and access to modern contraceptives among adolescent girls. Nakhumicha said that investments in youth-friendly reproductive health services at the grassroots will be key to minimizing the risk of adolescent pregnancies and sexually transmitted infections.

She added that community health volunteers, cultural and religious leaders, and law enforcement officers will be engaged in the new campaign to end teenage pregnancies as well as gender-based violence.

"Digital tools will help us track and identify perpetrators of gender-based violence. Our criminal justice system should fast-track prosecution of offenders who include intimate partners to act as a deterrent measure," said Nakhumicha. ■

case study of hiv aids in kenya

Kenya launches strategy to combat HIV/AIDS, teenage pregnancies, gender violence

Source: Xinhua

Editor: huaxia

2024-02-25 00:05:15

NAIROBI, Feb. 24 (Xinhua) -- Kenya's Ministry of Health on Saturday launched a strategy to eliminate the triple threats of HIV/AIDS, teenage pregnancies, and gender-based violence that have reversed progress towards achieving the UN 2030 goals.

Susan Nakhumicha, the cabinet secretary in the Ministry of Health, reaffirmed the government's commitment to leveraging a host of policy and legislative tools to end new HIV infections, adolescent pregnancies, and gender-based violence.

"We have started the journey to eliminate the triple public health crisis of HIV/AIDS, teenage pregnancies, and sexual and gender-based violence in line with our commitment to national and international conventions," Nakhumicha said at the launch that was held in western Kenyan county of Bungoma.

Kenya has 1.5 million people living with HIV and more than 90 percent on life-saving drugs, according to Nakhumicha, who decried the high rate of infections among youth aged 15 years to 24 years. She reiterated the government's commitment to ending HIV/AIDS by 2030 by preventing new infections among high-risk demographics like youth and women alongside expanding access to life-long treatment.

In addition, Nakhumicha said the rollout of the Social Health Insurance Fund will ensure that antiretroviral therapy is affordable to persons living with HIV.

To help curb teenage pregnancies that have also been linked to new HIV infections, Nakhumicha said the government will leverage technology, grassroots campaigns, and access to modern contraceptives among adolescent girls. Nakhumicha said that investments in youth-friendly reproductive health services at the grassroots will be key to minimizing the risk of adolescent pregnancies and sexually transmitted infections.

She added that community health volunteers, cultural and religious leaders, and law enforcement officers will be engaged in the new campaign to end teenage pregnancies as well as gender-based violence.

"Digital tools will help us track and identify perpetrators of gender-based violence. Our criminal justice system should fast-track prosecution of offenders who include intimate partners to act as a deterrent measure," said Nakhumicha. ■

case study of hiv aids in kenya

case study of hiv aids in kenya

HIV Recency Testing Can Identify New Infections Earlier, ICAP and Rwanda Biomedical Center Evaluation Finds

Feb 25, 2024 | News

case study of hiv aids in kenya

No Increased Intimate Partner Violence Associated with Recency Testing

For people newly diagnosed with HIV in Rwanda, HIV recency testing is part of standard national HIV case-based surveillance, distinguishing recent infection – less than six to 12 months – from long-term infection, which indicates an infection that took place more than a year earlier. Rwanda also offers index testing and partner notification services as part of case-based surveillance.

In 2018, Rwanda adopted HIV recency testing for people newly diagnosed with HIV to inform HIV prevention and testing interventions to help the country reach epidemic control. In 2021-22, with support from the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) through the U.S. Centers for Disease Control and Prevention (CDC), ICAP collaborated with the Rwanda Biomedical Center (RBC) to evaluate HIV recency testing. Findings show that recent infections are more common in contacts of people newly diagnosed with HIV who, themselves, have been recently infected.

“For HIV care and treatment in Rwanda, recency testing means we can catch people earlier. It is estimated that only 84% of the population living with HIV in Rwanda know their status,” said Suzue Saito, PhD, Strategic Information Unit director and TRACE project director for ICAP at Columbia University. “HIV recency testing with index testing and partner notification services provides an important opportunity to identify new infections earlier and tailor prevention efforts to high-risk groups to help Rwanda reach epidemic control,” she said.

Conducted in 60 health facilities across five provinces in Rwanda, the study enrolled a cohort of 1,238 newly diagnosed individuals 15 years and older. As part of index testing, the enrollees shared the contact information of their sexual partners. Health care providers invited sexual partners they successfully contacted to health facilities for HIV testing and recency testing if HIV-positive.

Results show that out of 1238 people newly diagnosed with HIV, 98 (7.9%) had a recent infection at the time of HIV diagnosis. People with recent HIV infection were more likely to be under 35 years of age, female, and single compared to people with long-term infection. They were also more likely to identify as female or men who have sex with men. Their sexual contacts were also more likely to be younger than 35 years and were more likely to be male, casual partners.

The 1238 people listed a total of 1738 sexual contacts; 164 were linked to the 98 recent cases, and 1574 were linked to 1140 long-term cases. Of the 1738 sexual contacts, 789 were tested for HIV, 123 (15.5%) were HIV positive, and 9 (1.1%) were recent infections. Researchers identified a greater proportion of recent infections (3/75, 4%) among contacts of newly diagnosed people living with HIV who themselves were recently infected compared to those with long-term infections (6/714, 0.8%).

The study also evaluated intimate partner violence (IPV) among this cohort of individuals. “PEPFAR does not recommend returning recency results to newly diagnosed persons living with HIV partly due to lack of evidence that returning results will not increase the experience of intimate partner violence,” said Gallican Rwibasira, MBBS, MPH, head of the Division for HIV and STIs Programs, RBC. “We, therefore, decided to measure experiences of intimate partner violence prior to and following HIV diagnosis and the return of recency results in Rwanda as part of our overall study evaluation, and the results showed that intimate partner violence did not significantly increase after the return of recency test results.”

There was also no difference observed in experiences of IPV between recent and long-term study participants before or after the return of recency results. “We know that IPV is prevalent. What we hope is that programs can adopt strategies to mitigate IPV risks while finding ways to support safe disclosure and ensure access to appropriate services that prioritize safety,” said Eugénie Poirot, PhD, MPH, a senior technical advisor in ICAP’s Strategic Information Unit.

The complete study report  is now available on the ICAP website. Results will continue to inform new ideas on the use of recency testing for prevention and testing programs, including index testing in Rwanda.

View Rwanda HIV Recency Evaluation Study Report

A major global health organization that has been improving public health in countries around the world for two decades, ICAP works to transform the health of populations through innovation, science, and global collaboration. Based at Columbia Mailman School of Public Health, ICAP has projects in more than 40 countries, working side-by-side with ministries of health and local governmental, non-governmental, academic, and community partners to confront some of the world’s greatest health challenges. Through evidence-informed programs, meaningful research, tailored technical assistance, effective training and education programs, and rigorous surveillance to measure and evaluate the impact of public health interventions, ICAP aims to realize a global vision of healthy people, empowered communities, and thriving societies. Online at icap.columbia.edu

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case study of hiv aids in kenya

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With a Clinic on Wheels, ICAP Moves Research on Opioids and HIV Into the Passing Lane

case study of hiv aids in kenya

In summer 2021, a state-of-the-art mobile clinic began making rounds in the streets of Harlem and the Bronx, drawing attention with its bright graphics. But beneath the colorful exterior is a serious proposition – to address the intertwined public health crises of opioid addiction, HIV, and hepatitis C among people who inject drugs.

Drug overdose is the leading cause of accidental death in the United States, with nearly 108,000 fatalities in 2021, the highest number of overdose deaths recorded in any 12-month period. Factors such as lack of access to health care, poverty, mental health disorders, use of multiple illicit substances, stigma and discrimination combine to increase the risk of HIV transmission and acquisition and other health issues among people who inject drugs.

The mobile clinic is at the center of ICAP’s participation in the nationwide INTEGRA study (HPTN 094), which aims to determine whether using mobile health units to deliver integrated health services for people with opioid use disorder can improve addiction, HIV, hepatitis C and substance use outcomes compared to standard of care. At locations frequented by people who inject drugs, ICAP study team members engaged with individuals, provided them with information regarding the study, enrolled participants and followed up with them throughout their study participation.

Participants in the study are randomized to receive integrated care on the “van” – as the study team calls it – or to receive the services of a health care navigator who will assist the participant in finding care in the community.

“The integrated care model means they will be able to receive their buprenorphine [a medication to treat opioid use disorder] prescription from the van,” said Rashaunna Redd, NP, site clinician for ICAP’s Bronx Prevention Center, which conducts the study. “And they will also be tested for HIV, STIs, and hepatitis, and screened for routine primary care problems such as diabetes and blood pressure issues.”

After six months, all participants transition to care in the community. Follow-up after the study extends to 12 months.

“Our goal is to make it as close to one stop as a possible. Although we recognize that some people will have serious medical conditions that require them to see specialists – and we will help them with that,” said Ellen Morrison, MD, site lead at ICAP’s Bronx Prevention Center.

Since the study began, initial findings revealed a high prevalence of mental health disorders such as anxiety, depression, and post-traumatic stress disorder among participants.

“This finding is particularly important because recreational drug use may be used as a form of self-medication,” said Alan Padilla, BA, community educator at ICAP’s Bronx Prevention Center. “Our team is actively promoting the need to address these underlying factors to fully provide addiction services.”

As the van proclaims in bright lettering, ICAP is driving health forward . Mobile health units, along with this study, are providing the engine necessary to reach that mission.

Funder: U.S. National Institute of Allergy and Infectious Diseases (NIAID) with funding from the U.S. National Institute on Drug Abuse (NIDA)

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As COVID-19 swept the globe, its ruthless trajectory exacerbated the challenges and inequities already faced by the lesbian, gay, bisexual, transgender, and queer (LGBTQ+) community, including employment and housing discrimination, inequitable health care, and more. To gain insight into the burden and impact of COVID-19 on this community, and assess vaccine uptake, ICAP conducted a study that reached more than 1,000 LGBTQ+ New Yorkers aged 18 to 68 years.

While LGBTQ+ individuals in NYC reported a similar burden of COVID-19 and vaccine uptake compared to the general population of the city, the study revealed this community is more likely to experience increased financial and emotional challenges due to the pandemic, particularly among the most stigmatized, such as gender minorities and among those with multiple minority identities. For example, 81 percent of LGBTQ+ individuals reported experiencing financial hardship as a result of the pandemic. This important evidence base will inform strategies to reach unvaccinated individuals and assist policymakers in developing further programs to support those most negatively impacted by the pandemic.

Funder: Rockefeller Foundation

Project: Experiences of LGBTQ+ Populations in New York City During the COVID-19 Pandemic (The LEXICON Study)

COVID-19 and Older Adults in New York City: A Landmark Study

In New York City, older adults had seven times the mortality rate from COVID-19 compared to all other ages, but there was little known about the mental health and social ramifications of the pandemic on this population – especially those who were still living at home and not in nursing homes.

To gain a better understanding of the effects of the pandemic on this vulnerable group, ICAP launched the SARS-CoV-2 Impact on Lives and Views of Elderly Residents (SILVER) study, aimed at understanding the physical, emotional, and economic effects of the COVID-19 pandemic on older adults living at home. A total of 676 participants 70 years and older were enrolled – overall, 18 percent of older adults screened for depression and 17 percent for anxiety, with a greater percent of Latinx older adults reporting loneliness than other races and ethnicities. Almost one-third of older New Yorkers reported financial challenges and almost one in ten reported not having enough to eat.

With new funding, ICAP launched a second SILVER study seeking to learn more about the impact of the pandemic on participants’ ongoing health and wellbeing. The second round of data collection expanded topic areas, pursuing further details about participants’ access to resources such as telehealth, housing, internet, social support, and use of city services. Attitudes toward the COVID-19 vaccine, booster doses, and the influenza vaccine were also evaluated. In addition to following up with the first SILVER study participants, the second study included new participants, specifically Asian New Yorkers, to better represent the diversity of New York City. The ultimate goal of the study was to provide policymakers in New York City and other communities with more accurate information on how to best serve and assist older adults during times of crisis.

Funder: New York Community Trust

Project: SARS-CoV-2 Impact on Lives and Views of Elderly Residents (SILVER) Study

IMAGES

  1. HIV in Kenya Infographic

    case study of hiv aids in kenya

  2. (PDF) Country-wise collaborations in HIV/ AIDS research in Kenya and

    case study of hiv aids in kenya

  3. (PDF) The impact of HIV and AIDS research: a case study from Swaziland

    case study of hiv aids in kenya

  4. (PDF) HIV/AIDS in Kenya: A Social Work Perspective

    case study of hiv aids in kenya

  5. Response to HIV

    case study of hiv aids in kenya

  6. case study of hiv aids in kenya

    case study of hiv aids in kenya

COMMENTS

  1. Prep Roll Out in A National Public Sector Program: the Kenyan Case Study

    BACKGROUND. The Joint United Nations Programme on HIV/AIDS has called for a 75% reduction in new HIV infections by 2020 and a fast track strategy to end the global epidemic by 2030 1.In Kenya, the Kenya AIDS Strategic Framework (KASF) similarly aims at reducing HIV infections by 75% by 2020, and the Kenya HIV Prevention Revolution Roadmap defines a multipronged approach aimed at reducing new ...

  2. HIV and forced sterilisations: How four Kenyan women found justice

    Four women living with HIV in Kenya have each been awarded $20,000 (£16,000) in damages for being sterilised without their informed consent. They have spoken to the BBC about their experiences ...

  3. HIV Incidence, Recent HIV Infection, and Associated Factors, Kenya

    Of 1,523 HIV-positive participants in 2018, 11 were classified as recent. Annual HIV incidence was 0.14% in 2018 [95% confidence interval (CI) 0.057-0.23], representing 35,900 (95% CI 16,300-55,600) new infections per year in Kenya among persons aged 15-64 years. The percentage of HIV infections that were determined to be recent was ...

  4. HIV Situation in Kenya

    Sex Workers Sex workers have the highest reported HIV prevalence of any group in Kenya. The most recent data from 2011 estimates 29.3% of female sex workers are living with HIV. Similarly, a 2015 study of female sex workers in Nairobi found that around one-third were living with HIV.

  5. PDF KENYA HIV ESTIMATES

    It is with pleasure that we launch the 2018 Kenya HIV Estimates Report; a product of hard work, resilience, and renewed commitment to ending AIDS by 2030. The 2017 Kenya HIV Estimates Report seeks to provide insight into the HIV epidemic in Kenya, and offers critical input into the impact of key interventions. The Report has

  6. Active pediatric HIV case finding in Kenya and Uganda: A look at missed

    PMID: 32484815 Active pediatric HIV case finding in Kenya and Uganda: A look at missed opportunities along the prevention of mother-to-child transmission of HIV (PMTCT) cascade

  7. A national household survey on HIV prevalence and clinical ...

    The KENPHIA survey confirms a substantial HIV burden among children in Kenya, especially among orphans.

  8. HIV and AIDS Epidemic in Kenya: An Overview

    The first case of HIV was reported in 1984. Between 1983 and 1985, 26 cases of AIDS have been reported. Sex workers were the first group to be affected—a study conducted in 1985 reported an HIV prevalence of 59% among the group in the Nairobi region, the capital city of Kenya.

  9. Clinical outcomes among adolescents living with HIV in Kenya following

    In Kenya, HIV/AIDS remains a leading cause of morbidity and mortality among adolescents living with HIV (ALHIV). Our study evaluated associations between demographic and healthcare factors and HIV treatment outcomes among ALHIV in care in Kenya. This retrospective cohort study evaluated the clinical outcomes of newly diagnosed ALHIV enrolled in HIV care during January 2017-June 2018 at 32 ...

  10. VMMC Programmatic Successes and Challenges: Western Kenya Case Study

    VMMC Programmatic Successes and Challenges: Western Kenya Case Study Curr HIV/AIDS Rep. 2022 Nov 29. doi: 10.1007/s11904-022-00644-8. Online ahead of print. Authors Kawango Agot 1 , Jacob Onyango 2 , Marylyn Ochillo 2 , Elijah Odoyo-June 3 Affiliations 1 Impact Research and Development ...

  11. PDF A Case Study Community-Based HIV/AIDS Prevention, Care, and Support Program

    With Support from Pathfinder in Kenya Community-Based HIV/AIDS Prevention, Care, and Support Program A Case Study This case study was made possible by support from the U.S. Agency for International Development (USAID) and the U.S. President's Emergency Plan for AIDS Relief under the terms of Cooperative Agreement GPO-A-00-03-00003-00.

  12. HIV and AIDS

    Resources Research and Reports Unintended pregnancies and HIV among adolescents and young people Situation Analysis of Children and Women in Kenya, 2017

  13. HIV/AIDS in Kenya

    Kenya has a severe, generalized HIV epidemic, but in recent years, the country has experienced a notable decline in HIV prevalence, attributed in part to significant behavioral change and increased access to ARV (antiretroviral drugs).

  14. At a glance: HIV in Kenya

    Prevention Preventing HIV in Kenya focuses on: condom provision comprehensive sexuality education PEP PrEP (oral PrEP is available; a PrEP vaginal ring and injection are being trialled) gender-based violence prevention a range of prevention services for young people, particularly adolescent girls and young women voluntary medical male circumcision

  15. The prevalence of HIV/AIDS frames in Kenya Newspapers: A summative

    Specifically, this analysis focuses on multiple frames used by stakeholders with respect to the following topical categories (a) valence (positive/negative), (b) the action frame, (c) victim frame, (d) severity of HIV/AIDS in Kenya, (e) causes and solutions, and (f) beliefs about who is at risk.

  16. (PDF) HIV/Aids and land: Case studies from Kenya ...

    The first HIV/AIDS case in Kenya was reported in 1984. By . June 2000, 1.5 million people in Kenya had died of AIDS. ... Specifically, the study suggests that the HIV/AIDS pandemic is causing ...

  17. Understanding mother-to-child transmission of HIV among mothers engaged

    Mother-to-child transmission of HIV, which may occur in utero, during birth, or through breastmilk, is now largely preventable with the advancement of HIV testing and treatment for women and their infants. Globally, great progress has been recorded over the years, with a 58% decline in new infections in children from 2010 to 2022. Currently, Kenya is among the countries with the highest rates ...

  18. PDF Hiv Case-based Surveillance in Kenya

    Guidelines for implementing HIV Case-Based Surveillance in Kenya 1 1. Introduction to HIV Case-Based Surveillance 1.1 Background In 2018, the prevalence of HIV in Kenya was estimated at 4.9% with an estimated 1.5 million adults and children infected with HIV nationwide (1). HIV prevalence varies with gender, with

  19. Kenya records rise in new HIV infections in over a decade

    By Angela Oketch & Mercy Chelangat HIV infection in the country has increased for the first in ten years, a new report has shown. The World Aids Day report 2022 to be released today indicated that the country has recorded an increase in new HIV infections for the first time in a decade with more than 2,000 cases from 32,025 to 34, 540.

  20. Widowhood in the era of HIV/AIDS: a case study of Slaya District, Kenya

    Widowhood in the era of HIV/AIDS: a case study of Slaya District, Kenya. 2007 Aug;4 (2):606-15. doi: 10.1080/17290376.2007.9724882. Luo women are believed to acquire contagious cultural impurity after the death of their husbands that is perceived as dangerous to other people. To neutralise this impure state, a sexual cleansing rite is observed.

  21. Active pediatric HIV case finding in Kenya and Uganda: A look at ...

    Background Children living with HIV remain undiagnosed due to missed opportunities along the prevention of mother-to-child HIV transmission cascade. This study addresses programmatic gaps in the cascade by describing pregnancy and HIV-related services received by mothers of children newly identified as HIV-positive through active case finding. Methods This was a prospective observational ...

  22. ICTs and monitoring of MDGs: a case study of Kenya HIV/AIDS monitoring

    Based on the case study of the Kenya National HIV/AIDS Programme, the paper takes an institutional theory perspective to identify the main competing logics producing misalignment between policy discourses and their enactments by different policy actors engaged in the restructuring of HIV/AIDS monitoring and evaluation systems. Poor donor-aid ...

  23. Cost analysis of implementing HIV drug resistance testing in Kenya: a

    Curr Opin HIV AIDS. 2011; 6 (4):251-257. 10.1097/COH.0b013e32834732e8 [Google Scholar] Gachogo R, Mwai D, Onyambu F: Cost analysis of implementing HIV drug resistance testing in Kenya: a case study of a service delivery site at a tertiary level hospital in Kenya. figshare. Dataset.2020a.

  24. Assessing accessibility of sexual reproductive health services among

    The study showed a statistically significant difference in the proportion of AYP living with HIV/AIDS who accessed SRH services in the study counties of Nairobi city and Homabay. Background: Sexual and reproductive health rights (SRHR) are fundamental human rights enshrined in national, regional, and international laws and agreements. This study aimed to determine the accessibility of SRHR ...

  25. Top 10 Counties With Highest HIV Infection Rates In Kenya

    According to the 2022 World Aids Days report, in the last 10 years, Kenya has doubled the number of people diagnosed with HIV and on life-saving antiretroviral treatment from 490,437 in 2012 to 1,122,334 million people at the end of 2021, with 73.3% of those on treatment attaining viral suppression.

  26. Mortality and associated factors among people living with HIV admitted

    Background Hospital admission outcomes for people living with HIV (PLHIV) in resource-limited settings are understudied. We describe in-hospital mortality and associated clinical-demographic factors among PLHIV admitted at a tertiary-level public hospital in Uganda. Methods We performed a cross-sectional analysis of routinely collected data for PLHIV admitted at Kiruddu National Referral ...

  27. Kenya launches strategy to combat HIV/AIDS, teenage ...

    Kenya has 1.5 million people living with HIV and more than 90 percent on life-saving drugs, according to Nakhumicha, who decried the high rate of infections among youth aged 15 years to 24 years. She reiterated the government's commitment to ending HIV/AIDS by 2030 by preventing new infections among high-risk demographics like youth and women ...

  28. Kenya launches strategy to combat HIV/AIDS, teenage pregnancies, gender

    Kenya has 1.5 million people living with HIV and more than 90 percent on life-saving drugs, according to Nakhumicha, who decried the high rate of infections among youth aged 15 years to 24 years. She reiterated the government's commitment to ending HIV/AIDS by 2030 by preventing new infections among high-risk demographics like youth and women ...

  29. HIV Recency Testing Can Identify New Infections Earlier, ICAP and

    No Increased Intimate Partner Violence Associated with Recency Testing. For people newly diagnosed with HIV in Rwanda, HIV recency testing is part of standard national HIV case-based surveillance, distinguishing recent infection - less than six to 12 months - from long-term infection, which indicates an infection that took place more than a year earlier.