Evaluating strategies to improve HIV care outcomes in Kenya: a modelling study

Jack J Olney,Paula Braitstein,Jeffrey W Eaton,Edwin Sang,Monicah Nyambura,Sylvester Kimaiyo,Ellen Mcrobie,Joseph W Hogan,Timothy B Hallett

doi:10.1016/s2352-3018(16)30120-5

Jack J Olney, Paula Braitstein + Show 7 more

Open Access

https://doi.org/10.1016/s2352-3018(16)30120-5

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Abstract

SummaryBackgroundWith expanded access to antiretroviral therapy (ART) in sub-Saharan Africa, HIV mortality has decreased, yet life-years are still lost to AIDS. Strengthening of treatment programmes is a priority. We examined the state of an HIV care programme in Kenya and assessed interventions to improve the impact of ART programmes on population health.MethodsWe created an individual-based mathematical model to describe the HIV epidemic and the experiences of care among adults infected with HIV in Kenya. We calibrated the model to a longitudinal dataset from the Academic Model Providing Access To Healthcare (known as AMPATH) programme describing the routes into care, losses from care, and clinical outcomes. We simulated the cost and effect of interventions at different stages of HIV care, including improvements to diagnosis, linkage to care, retention and adherence of ART, immediate ART eligibility, and a universal test-and-treat strategy.FindingsWe estimate that, of people dying from AIDS between 2010 and 2030, most will have initiated treatment (61%), but many will never have been diagnosed (25%) or will have been diagnosed but never started ART (14%). Many interventions targeting a single stage of the health-care cascade were likely to be cost-effective, but any individual intervention averted only a small percentage of deaths because the effect is attenuated by other weaknesses in care. However, a combination of five interventions (including improved linkage, point-of-care CD4 testing, voluntary counselling and testing with point-of-care CD4, and outreach to improve retention in pre-ART care and on-ART) would have a much larger impact, averting 1·10 million disability-adjusted life-years (DALYs) and 25% of expected new infections and would probably be cost-effective (US$571 per DALY averted). This strategy would improve health more efficiently than a universal test-and-treat intervention if there were no accompanying improvements to care ($1760 per DALY averted).InterpretationWhen resources are limited, combinations of interventions to improve care should be prioritised over high-cost strategies such as universal test-and-treat strategy, especially if this is not accompanied by improvements to the care cascade. International guidance on ART should reflect alternative routes to programme strengthening and encourage country programmes to evaluate the costs and population-health impact in addition to the clinical benefits of immediate initiation.FundingBill & Melinda Gates Foundation, United States Agency for International Development, National Institutes of Health.

Highlights

The provision of antiretroviral therapy (ART) has substantially reduced HIV mortality.[1]
Differences in care-seeking behaviour between patients who actively seek care and those who are actively sought lead to fundamental uncertainties in the operation of the care cascade, in particular, the extent to which health-careseeking behaviour enables patients to present for care and initiate treatment on becoming ill, bypassing the typical stages of pre-ART care, and monitoring until e592 www.thelancet.com/hiv Vol 3 December 2016
Among all AIDS-related deaths between 2010 and 2015, most occurred in individuals who had initiated treatment

Summary

Introduction

The provision of antiretroviral therapy (ART) has substantially reduced HIV mortality.[1]. The care cascade describes the series of engagements with the health system through which people with HIV must pass to benefit fully from ART, beginning with HIV testing, and ending with regular monitoring of patients in a state of sustained viral suppression. Data are typically available only for people with HIV who present to clinics and exclude those who never engage in care and who are likely to have the greatest health losses.[6,7] Differences in care-seeking behaviour between patients who actively seek care (through clinics) and those who are actively sought (through outreach programmes) lead to fundamental uncertainties in the operation of the care cascade, in particular, the extent to which health-careseeking behaviour enables patients to present for care and initiate treatment on becoming ill, bypassing the typical stages of pre-ART care, and monitoring until e592 www.thelancet.com/hiv Vol 3 December 2016

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