Brief on ART in Kenya

MINISTRY OF HEALTH
BRIEF ON ART IN KENYA OVER TIME
Introduction
Kenya has made significant progress in HIV control. An estimated 1.6 million persons are living
with HIV in Kenya (1.4 million adults and 191,000 children). The use of lifelong antiretroviral
therapy (ART) to manage HIV infection significantly reduces illness and mortality due to HIV. In
June 2014, the Ministry of Health launched revised guidelines for antiretroviral therapy (ART) that
recommend early initiation start of ART in children, adolescents and adults including all HIV
positive pregnant women. Based on these guidelines, of the 1.6 million PLHIV in Kenya, an
estimated 1.4 million will require antiretroviral therapy ART (1.23 million adults and 172,000
children aged less than 14 years).
As at February 2015, over 773,629 patients were on ART (702,000 adults aged 15 years and 71,000
children aged less than 15 years) representing 55% coverage of those in need of ART managed in
over 2000 health facilities in across the country. The Kenya AIDS Strategic Framework (KASF)
2014/15 -2018/19 has targeted to have at least 90% HIV infected persons know their status and
90% of those who know their status access ART by June 2019. Below is the ART Coverage trend
over time.
The figure below illustrates the increasing access to ART
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900,000
772,17
755,22
0
1
800,000
619,61
603,40
6
9
538,98
3
476,00
0
364,00
0
259,00
0
198,00
0
127,68
No of Patients on ART
700,000
600,000
500,000
400,000
300,000
200,000
0
70,800
24,000
10,000
100,000
0
2003
2004
70,000
14,000
21,000
29,000
36,000
48,546
55,439
66,070
8,800
57,895
2,900
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014 Feb‐15
Year
Peds on ART
Adults on ART
Total on ART
Evolution of treatment guidelines for ART
Since the introduction of HIV treatment in Kenya, the Ministry of health has provided National
Guidelines on Antiretroviral therapy that outlines eligibility for ARV use, regimen selection and
monitoring for Treatment. These guidelines are developed and reviewed in line with available local
and international evidence and in line with guidelines for public health provision of ART by the
World Health Organization through a process of stakeholder consultations and consensus.
The ART guidelines were first published 2001 and subsequently revised and updated in 2002, 2006,
2011 and 2014.
The figures below illustrate the guideline changes that have taken place over time:
a) Evolution of Paediatric ART Guidelines
2002 – 2005 Guidelines
2005 – 2008
When to initiate ART
<12 months with
Nov 2008 –Oct 2010
October 2010
June 2014
When to initiate ART
When to initiate ART
When
ART
to
<18 months
initiate
All children aged less than All children less than 2 All children aged 10
18 months irrespective of years irrespective of CD4 % years and below
All irrespective of clinical, CD4 <25% or CD4 ≤ CD4 % or count
or count
irrespective of CD4
immunologic or virologic status. 1500
% or count (test and
treat)
>12 months -12 years months- 18-59 months
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18-59 months
25- 59 months
>10 years
CD4 <25%
HIV RNA copies > 10,000/ml
CD4 <15% or CD4 ≤ CD4 <25% or CD4 ≤ 1000 CD4 <25% or CD4 ≤ 750 CD4
500
≤500/ml3
>5years
>5years-12 years
Count
>5years
CD4<15% or CD4 CD4<20% or CD4 Count CD4 Count ≤500/ml3
Count ≤200/ml3
≤350/ml3
CD4 independent
CD4 independent
CD4 independent
CD4 independent
All WHO stage
All WHO stage
All WHO stage
All WHO stage
3,4
3,4
3,4
3,4
b) Evolution of Adult ART Guidelines
2002 – 2005 Guidelines
2005 – 2007
When to initiate ART
Nov 2007 –Oct 2010
October 2010
June 2014
guidance)
(current
When to initiate ART
When to initiate ART
When to initiate ART
≤ 200 cells/mm3
≤ 200 cells/mm3
≤ 250 cells/mm3
≤ 350 cells/mm3
≤ 500 cells/mm3
Start ART
Start ART
Start ART
Start ART
Start ART
WHO stage 3 if CD4
≤ 350 cells/mm3
All HIV+
women
pregnant
All HIV+ in serodiscordant relationship
CD4 independent
CD4 independent
CD4 independent
CD4 independent
WHO stage 4
All WHO stage 3,4
All WHO stage 3,4
All WHO stage 3,4
Challenges/Key Issues in ART scale up
Children 0-14 years
x
Though immunization coverage at the 6 weeks immunization visit is over 90% in most
facilities, programmatic data indicates that only 60% of HIV exposed infants receive a HIV
test in the first 2 months of life. HIV antibody testing is recommended for children above 18
months of age.
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x
x
x
x
Results from Kenya Aids indicator survey (KAIS) 2012 show that only 16.4% of children
aged 18 months to 14 years had ever been tested for HIV, as reported by their parents or
guardians. Family testing for HIV-infected clients who attend HIV clinics is low. According
to KAIS, among children who had an HIV-infected parent, less than half (45.4%) had ever
been tested for HIV.
Further Only 40.5% of parents or guardians of HIV-infected children aged 18 months to 14
years were aware that their child was infected with HIV. In addition there are poor
mechanisms for referral and linkage of children who test HIV positive to care and treatment
at all facility entry points.
Program data shows that there is low coverage of Paediatric ART with only 41% of children
aged 0-14 years on ART. In addition to low coverage for HIV tests and Treatment for
children with HIV, continuity and Quality of Care for children accessing HIV services
remains a concern. National data indicates high loss to follow up for children in care and not
ART and lower retention among adolescents and those aged less than 5 years. The
programmatic cohort analysis conducted in 2014 showed retention of about 70% among the
under 5 and adolescents compared to other age groups on ART at 12 months.
Furthermore national studies indicate that only between 60-70% of children on ART are
virally suppressed against a national target of 90% suppression.
Adolescents
HIV?AIDS is the leading cause of death in Africa and the second largest cause of death amongst
adolescents globally.
Although data on adolescents is limited, an estimated 141,014 adolescents (10-19 years) are living
with HIV, 70% of them being girls. Of these 105,679 (75%) are estimated to be need of ART based
on national guidelines and overall viral suppression among adolescents is unknown.
According to KAIS 2012 only an estimated 42% of adolescents were accessing ART, a coverage that
may have declined with revised treatment guidelines.
Adults
As end 2014, 689,155 adults were receiving ART and currently there are over 780,000 PLHIV on
treatment with an overall treatment coverage of 52%. Overall adults on ART have higher viral
suppression rates based on national surveys averaging between 80-89%. The major barrier to ART
access for adults remains low knowledge of HIV status. (Kais 2012 @ 47% knowledge of status
among infected persons) while access for those who know status is high at about 90% (KAIS 2012).
Stigma and discrimination is still rife and affects access and retention to treatment. Retention data
from cohort analysis indicates that the overall retention of patients on ART has declined over the
years. ART retention at 12 months in 2011 was estimated at 92%, while retention over the same 12
months in 2013 declined to an average of 76%. Very young children (ages 0-4 years) and young
adults (ages 15-24 years) suffer the lowest retention; 70% and 67% respectively. This may portray
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the vulnerabilities either behavioural, high mortality risks among other factors that affect retention
amongst these subgroups.
Other Challenges:
x
x
Declining quality of care due to HR shortages , increasing patient numbers, inadequate
patient preparation because of HR constraints
Services that are not friendly to adolescents and youth eg the attitude of Health care workers
to HIV positive adolescents and the timing of business hours in hospitals
Response
The ministry of health has set pace to accelerate ART access for all children, adolescents and adults
to achieve the 2019 targets as set in KASF. This will include strengthening all areas of the cascade of
care from identification, linkage, ART initiation, retention and viral suppression. Key strategies
include increasing use of technology for linkage and tracking clients , age appropriate peer support
mechanisms , scaling up youth friendly services and systems support to enhance treatment
monitoring , ensuring commodity security and accountability by counties and stakeholders.
In addition the GOK has set in motion targeted initiatives to accelerate HIV prevention efforts
among adolescents through implementation of combination prevention and treatment access as part
of the ALL IN global campaign to end Adolescent new infections and AIDs.
We particularly thank H.E. the President for his commitment to accelerate treatment through the
launching of the global ALL IN ONE Campaign which aims to calls to action - listen, involve and
include young people - in efforts to reduce AIDS-related deaths and new HIV infections.
The launch presided by the Kenyan president Uhuru Kenyatta and lauded by various UN global
leaders, is a fresh call to act on the rising numbers of infection and death among global and African
youth. The campaign aims to achieve reductions in AIDS-related deaths by 65% and new HIV
infection by 75% by 2020
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