title: Cascade of HIV care and population viral suppression in a high-burden region of Kenya.
abstract: BACKGROUND
  Direct measurement of antiretroviral treatment (ART) program indicators essential for evidence-based planning and evaluation - especially HIV incidence, population viral load, and ART eligibility - is rare in sub-Saharan Africa.
  
  
  METHODS
  To measure key indicators in rural western Kenya, an area with high HIV burden, we conducted a population survey in September to November 2012 via multistage cluster sampling, recruiting everyone aged 15-59 years living in 3330 randomly selected households. Consenting individuals were interviewed and tested for HIV at home. Participants testing positive were assessed for CD4 cell count and viral load, and their infections classified as either recent or long term based on Limiting Antigen Avidity assays. HIV-negative participants were tested by nucleic acid amplification to detect acute infections.
  
  
  RESULTS
  Of 6833 household members eligible for the study, 6076 (94.7% of all women and 81.0% of men) agreed to participate. HIV prevalence and incidence were 24.1% [95% confidence interval [CI] 23.0-25.2] and 1.9 new cases/100 person-years (95% CI 1.1-2.7), respectively. Among HIV-positive participants, 59.4% (95% CI 56.8-61.9) were previously diagnosed, 53.1% (95% CI 50.5-55.7) were receiving care, and 39.7% (95% CI 37.1-42.4) had viral load less than 1000 copies/ml. Applying 2013 WHO recommendations for ART initiation increased the proportion of ART-eligible people from 60.0% (based on national guidelines in place during the survey; 95% CI 57.3-62.7) to 82.0% (95% CI 79.5-84.5). Among HIV-positive people not receiving ART, viral load increased with decreasing CD4 cell count (500-749 vs. ≥750 cells/μl, adjusted mean difference, 0.40 log10 copies/ml, 95% CI 0.20-0.60, P < 0.01).
  
  
  CONCLUSIONS
  This study demonstrates how population-level data can help optimize HIV programs. Based on these results, new regional programs are prioritizing diagnosis and expanding ART eligibility, key steps to reach undetectable viral load.
authors.affiliation: aEpicentre, Paris, France bCenters for Disease Control and Prevention, Kisumu cNational AIDS & STI Control Programme dMédecins Sans Frontières, Nairobi eCenter for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya fMédecins sans Frontières, Paris gService de biostatistique, Hospices Civils de Lyon, Lyon hUMI 233 TransVIHMI, Institut de Recherche pour le Développement, Montpellier 1 University, Montpellier, France.
authors.forename: David
authors.initials: D
authors.lastname: Maman
authors.forename: Clement
authors.initials: C
authors.lastname: Zeh
authors.forename: Irene
authors.initials: I
authors.lastname: Mukui
authors.forename: Beatrice
authors.initials: B
authors.lastname: Kirubi
authors.forename: Sophie
authors.initials: S
authors.lastname: Masson
authors.forename: Valarie
authors.initials: V
authors.lastname: Opolo
authors.forename: Elisabeth
authors.initials: E
authors.lastname: Szumilin
authors.forename: Benjamin
authors.initials: B
authors.lastname: Riche
authors.forename: Jean-François
authors.initials: JF
authors.lastname: Etard
mesh_terms: D000293:Adolescent; D000328:Adult; D044966:Anti-Retroviral Agents / Q000627:therapeutic use*; D000915:Antibody Affinity; D018791:CD4 Lymphocyte Count; D005260:Female; D015483:HIV Antibodies / Q000097:blood; D015658:HIV Infections / Q000175:diagnosis* / Q000188:drug therapy* / Q000453:epidemiology; D006297:Health Services Accessibility; D006298:Health Services Administration; D006302:Health Services Research; D006801:Humans; D015994:Incidence; D007630:Kenya / Q000453:epidemiology; D008297:Male; D012424:Rural Population; D019562:Viral Load; D055815:Young Adult
chemical_list: D044966:Anti-Retroviral Agents; D015483:HIV Antibodies