NEW YORK, NOVEMBER 23, 2020—Working with local health facilities to bring quality HIV/AIDS testing and treatment closer to communities improved public health and significantly reduced the percentage of the people living with HIV in Ndhiwa sub-county in Homa Bay, Kenya, according to a study released this month by the international medical humanitarian organization Doctors Without Borders/Médecins Sans Frontières (MSF) and its research arm, Epicentre.
For many years, Ndhiwa in Homa Bay had one of the highest HIV prevalence rates—the proportion of the population infected with the virus—in Kenya and across Africa. To tackle this, MSF and its partners rethought their approach to HIV care in the region and began working in 2014 to better provide HIV testing and treatment at a more decentralized, local level. Additionally, health workers began more immediately putting people who tested positive on antiretroviral therapy (ART), which helps keep HIV-positive people healthy while preventing further spread of the virus since ARTs reduce the amount of HIV in one’s body.
The study—Ndhiwa HIV Impact on Population Survey 2 (NHIPS 2)—was conducted between 2014 and 2018 and showed that, by 2018, 93 percent of the Ndhiwa’s population knew their HIV status (up from 59 percent according to a 2012 survey) and 97 percent of HIV-positive people were receiving ART treatment (up from 68 percent). Ninety-five percent of people receiving ART had completely suppressed the virus (up 11 percent from 2012). Additionally, between 2014 and 2018, the prevalence rate dropped from 24 to 17 percent, and the percentage of new infections per year among the population at risk decreased from 1.9 to 0.7 percent.
“The underlying principle is that, when your treatment is successful, the virus is suppressed and you are unable to pass it to other people,” said Dr. Mohammed Musoke, MSF medical coordinator in Kenya. “When applied to large numbers of people, HIV treatment equals HIV prevention. In practice, to achieve that goal, we worked to drive major improvements in the three main pillars of HIV care: increasing people’s awareness of their HIV status, maximizing the number of HIV-positive people on ART, and increasing the number of people on ART who have successfully suppressed the virus. By working on these three steps, we aimed to reduce the rates of new infections and, over time, the presence of the disease among the population."
The NHIPS 2 study confirms that the 2020 targets set by UNAIDS to bring the global HIV epidemic under control had been met and exceeded two years early in Ndhiwa. The “90-90-90” UN target—in which 90 percent of HIV-positive people know their status, 90 percent are on treatment, and 90 percent have a suppressed viral load—helps reduce the rates of new infections and sees treatment as prevention since lower viral loads mean less of a chance for someone with HIV to spread the virus.
The new approach of MSF and its partners, including the Kenyan Ministry of Health, boosted systematic testing through extensive engagement of the community, door-to-door health promotion campaigns, and household testing. Additionally, teams worked to increase access to ART and follow-up care for HIV-positive people. In 2012—when MSF did a previous survey to see how HIV care needed to be improved in the area and establish a baseline—treatment and follow-up were only available in the main hospitals and health centers of the area. Many of these centers were highly congested and difficult to reach, and, as a result, contact with patients was often lost before or during their treatment. Only six percent of the HIV-positive population could be treated in local health facilities.
Starting in 2014, MSF and its partners expanded and improved HIV care in smaller, rural health facilities through better staffing and more regular supplies, including ARTs. Teams also worked to strengthen the referrals of newly diagnosed people into the health care system. The turnaround of laboratory tests became faster and more efficient thanks to a network of motorbike riders who collected blood samples in local health centers and transported them to the nearest lab facility. This represented a dramatic improvement from the time when patients had to travel a long way to be tested and often waited months to know the results and even longer to be put on ART.
“The investment in a laboratory system was a key part of the process, as medical staff rely on these tests to know what to treat, how to treat it, and whether the treatment is actually working,” Dr. Musoke said. “By testing at the point of care and using better equipment, results that used to take days or weeks to get back, could now be returned in an hour or less.”
In 2016, the Kenyan Ministry of Health adopted the World Health Organization recommendation to systematically “test and treat,” which has now become a cornerstone of HIV care in the region. This approach puts people who test positive for HIV on ART immediately. It has, so far, been cost-effective, but it relies on sustained investment and commitment from international donors like the US President's Emergency Plan for AIDS Relief (PEPFAR), without which the gains obtained over the past five years might be lost. Additionally, it is critical that local partners continue to support this new approach of decentralized testing and care and make sure ARTs are consistently available.
“While the results achieved are the best that we could expect, given the resources and the constraints, prevalence and incidence rates remain higher than the levels needed to control the HIV epidemic,” Dr Musoke said. "The fight against HIV in Ndhiwa is far from over, and efforts to work on the main pillars of HIV care have to continue if these gains are to be maintained and improved upon.”
MSF has been working in Homa Bay since 1997. Teams currently support 38 facilities in Ndhiwa and run two adult in-patient wards for very sick HIV/AIDS patients, a TB ward, and a discharge clinic for post-discharge follow-up at the Homa Bay county teaching and referral hospital. The NHIPS 2 study covered 6,020 people aged 15 to 59 living in Ndhiwa, which has a population of 114,480. The results were compared to the findings of a similar 2012 MSF/Epicentre survey of 6,150 people aged 15 to 59 in the same area. Participants completed detailed questionnaires and had an HIV test. If confirmed HIV-positive, further blood tests were taken to measure viral load and CD4 counts.