Wider ART Rollout Tied to Declines in HIV Mortality in Kenya

SEATTLE -- Both all-cause mortality and mortality among HIV-positive people dropped in Western Kenya following a scale-up of antiretroviral therapy (ART), a researcher said here.

From 2011 to 2016, all-cause mortality dropped from 10.0 per 1,000 person years (95% CI 8.4-11.7) to 7.5 per 1,000 person years (95% CI 5.8-9.1), reported Emily C. Zielinski-Gutierrez, DrPH, of the CDC.

These declines were mainly driven by a decline in the deaths of HIV-positive people, falling from 30.5 per 1,000 to 15.9 per 1,000, or an average decline of 6% per year, according to a presentation at the Conference on Retroviruses and Opportunistic Infections.

The researchers noted that HIV mortality rates declined by 10-20% initially after the introduction of antiretroviral therapy from 2003 to 2011, but there is limited information on HIV mortality after 2011. The team looked at western Kenya specifically, where the bulk of the HIV epidemic in that country is located, Zielinski-Gutierrez said. Moreover, ART coverage in western Kenya had increased from 34% in 2011 to 60% in 2016, she noted.

With lack of a "civil registration system," the researchers were forced to get creative. They analyzed mortality and migration data from the Health Data and Demographic Surveillance System and HIV data, described as "a cohort of people we follow routinely to look at in and out migration," and data from four rounds of home-based HIV testing, comprised of a door-to-door intervention offering HIV testing.

Overall, about 23,000 residents ages 15-64 made up the cohort. The authors found that while there was an overall decline in all-cause mortality, mortality among HIV-negative people remained stable over the course of the study (5.7 per 1,000), meaning the decline was driven by decreases in mortality among HIV-positive people.

"What this tells us is during this period of intensive ART expansion in this community we saw a substantial decline in HIV-associated mortality, but at the same time mortality among HIV-positive people still far exceeds HIV negative neighbors," Zielinski-Gutierrez said.

Indeed, HIV-positive people on ART had higher mortality rates than HIV-negative people (adjusted mortality RR 2.8, 95% CI 2.2-3.4), and those rates were even higher among HIV-positive people who were not on ART (adjusted RR 5.3, 95% CI 4.5-6.2).

The researchers noted that antiretroviral therapy uptake was likely underestimated, due to "self-report and lack of clinic-based linkage."

"This argues for the fact that we have to be able to routinely track mortality in these highly effected communities in order to understand the epidemic trends," Zielinski-Gutierrez said. "Having a health and demographic surveillance system really enables us to better understand what otherwise might be very difficult to track in areas that don't have good mortality tracking systems as part of routine civil service."

The authors said that the "moderate" reduction in mortality seen here may be insufficient to reach Fast Track goals that aim to reduce HIV mortality, though with the expansion of the Treatment for All program, additional gains are anticipated.