Abstract
From 2004 to 2014, the US President's Emergency Plan for AIDS Relief (PEPFAR) invested more than $248 000 000 in the prevention of mother-to-child transmission (PMTCT) of HIV in Kenya. Concurrently, child mortality in Kenya decreased by half. To identify the extent to which the decrease in child mortality in Kenya is associated with PEPFAR funding for PMTCT of HIV. This population-based survey study conducted in Kenya estimated the association between annual per capita PEPFAR funding for PMTCT (annual PCF) and cumulative per capita PEPFAR funding for PMTCT (cumulative PCF), extracted using 2004-2014 country operational reports as well as individual-level health outcomes, extracted from the 2003, 2008-2009, and 2014 Kenya Demographic and Health Surveys and the 2007 and 2012 Kenya AIDS Indicator Surveys. The study included children of female respondents to the 2003, 2008-2009, and 2014 Kenya Demographic and Health Surveys who were born 1 to 60 months (for neonatal mortality) or 12 to 60 months (for infant mortality) before the survey, as well as female respondents who had recently given birth and reported on HIV testing during antenatal care (ANC) during the 2007-2014 surveys. Results were adjusted for year, province, and survey respondent characteristics. Statistical analysis was performed from July 8, 2016, to December 10, 2018. Neonatal mortality was defined as death within the first month of life and infant mortality was defined as death within the first year of life. HIV testing during ANC was defined as receiving counseling on PMTCT, undergoing an HIV test, and receiving test results during ANC. The analysis included 33 181 neonates (16 870 boys), 26 876 infants (13 679 boys), and 20 775 mothers (mean [SD] age, 28.0 [6.7] years). PEPFAR funding was not associated with neonatal mortality. A $0.33 increase in annual PCF, corresponding to the difference between the 75th and 25th (interquartile range) percentiles of funding, was significantly associated with a 16% (95% CI, 4%-27%) reduction in infant mortality after a 1-year lag. A 14% to 16% reduction persisted after 2- and 3-year lags, and comparable reductions were observed for unlagged and 1-year lagged cumulative PCF. An increase of 1 interquartile range in cumulative PCF was associated with a 7% (95% CI, 3%-11%) increase in HIV testing during ANC, which intensified with subsequent lags. Between 2004 and 2014, sustained funding levels of $0.33 annual PCF could have averted 118 039 to 273 924 infant deaths. Evidence from publicly available data suggests that PEPFAR's PMTCT funding was associated with a reduction in infant mortality and an increase in HIV testing during ANC in Kenya. The full outcome of funding may not be realized until several years after allocation.
Highlights
Between 1988 and 2003, Kenya experienced a 32% increase in mortality among children younger than 5 years, which has been partially attributed to the HIV epidemic.[1,2] In response, Kenya established prevention of mother-to-child transmission (PMTCT) of HIV programs in more than 10 000 facilities.[3]
An increase of 1 interquartile range in cumulative per capita funding (PCF) was associated with a 7% increase in HIV testing during antenatal care (ANC), which intensified with subsequent lags
We assigned 53% of total planned President’s Emergency Plan for AIDS Relief (PEPFAR) expenditures for PMTCT to specific provinces; the remainder could not be assigned to specific provinces either because they had been allocated to nationwide programs (16%) or implementing partners working across province borders (10%) or because there was insufficient information to assign funding to a specific implementing partner (20%)
Summary
Between 1988 and 2003, Kenya experienced a 32% increase in mortality among children younger than 5 years, which has been partially attributed to the HIV epidemic.[1,2] In response, Kenya established prevention of mother-to-child transmission (PMTCT) of HIV programs in more than 10 000 facilities.[3]. PEPFAR’s investments in PMTCT coincided with a halving of the mortality rate among children younger than 5 years in Kenya,[5] it is unknown whether this improvement can be attributed to PEPFAR funding for PMTCT. Programs for PMTCT provide a series of interventions, including provision of HIV testing during antenatal care (ANC), prescription of antiretroviral medication to HIV-positive mothers and exposed infants, and counseling on safe breastfeeding practices, which are critical to the survival of children born to HIV-positive mothers.[6] Without PMTCT, 25% to 48% of children born to HIV-positive mothers become HIV positive, and, in low-resource settings, 50% of HIV-positive children who do not receive treatment die before 2 years of age.[7,8] child mortality decreased in most sub-Saharan African countries during the 2000s,9 and regional trends, rather than PEPFAR funding, could explain all or part of Kenya’s reductions in child mortality. PEPFAR-funded activities targeting adults could have displaced essential newborn and infant health services,[10,11] resulting in worsened child health outcomes
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