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Evidence for optimizing highly active antiretroviral treatment (HAART) in Kenya Dr. Washingtone Ochieng • CNHR RCDG Fellow returning from Harvard University, U.S.A • Research Host: CREATES Summary: HIV Prevalence & treatment Declining prevalence, rising numbers! • Longevity- ART • More PLWH TREATMENT • ARV access improved • Monitoring not so • Adherence & failure Study sites Relevance to Policy • Great progress at controlling the HIV epidemic, but • Exposure trends and sources are increasing • Substance use, Commercial sex, same sex etc. • Increased ARV access- likely to drive resistance and misuse • Weak monitoring structures- need evidence-backed guidance Treatment failure and underlying influencers • Overall, 35.9% of all patients failed treatment • Failure highest among Patients receiving D4T(stavudine) regimen • First-line D4T discontinued elsewhere but still widely used in Kenya • 33.3% of the patients developed resistance to major drugs in use • Single viral load test is efficient for treatment failure definition Peer support improves adherence & treatment outcome Adherence Viral load Peer Support * * * * * * • Patients active in peer support programs had good adherence • Patient with good adherence had lower viral load HIV as a collection of sub-epidemics of many virus strains SUBTYPE/Strain A B C D Recombinants % HIV diversity within in Envelope (vaccine target) Pol (drug target) 79 0 0 0 21 • Observed increased diversity of HIV in the drug-target genes • Identified HIV-1 subtype B, only common in Europe & the Americas • Multiple strains complicate disease & treatment outcomes 67 5 14 10 5 Increased burden of infection among substance users. • 66.2% injectors and 33.8% non-injectors • HIV-1 prevalence; 87.5% among injectors. • Hepatitis C prevalence; injectors (16.3%) & non-injectors (4.3%) Policy decision-points: ①Implement point-of-care viral load testing to monitor failure ②Implement patient-focused adherence support programs Strengthen patient-physician and patient-patient relationships ③Regularize drug toxicity testing- D4T regimen phase-out per WHO ④Institutionalize drug resistance testing (reference testing centers) ⑤Capacity building- train and impart relevant skills on testing Policy decision-points-cont… 6). Public health approach to alleviate behavioral risks • Substance replacement therapy; treatment-as-a-prevention • Pre-exposure prophylaxis; Test-and-treat’; self-reporting support 7). Ministry of Health to partner with research groups to • Support research activities that will enhance informed policy decisions • Actively monitor disease epidemiology and genetics Summary • HIV treatment access has improved- Monitoring needs scaling • Patient Participation in adherence programs useful • Drug/substance abuse compromising gains • Policy decisions to intersect with Research evidence • Other outcomes: • Graduate & undergraduate trainings, publications, Conferences Acknowledgement • Centre for Research in Therapeutic Sciences (CREATES) • Consortium for National Health Research (CNHR) for funding