Low levels of viral suppression among refugees and host nationals accessing antiretroviral therapy in a Kenyan refugee camp

Abstract

BackgroundRefugees and host nationals who accessed antiretroviral therapy (ART) in a remote refugee camp in Kakuma, Kenya (2011–2013) were compared on outcome measures that included viral suppression and adherence to ART.MethodsThis study used a repeated cross-sectional design (Round One and Round Two). All adults (≥18 years) receiving care from the refugee camp clinic and taking antiretroviral therapy (ART) for ≥30 days were invited to participate. Adherence was measured by self-report and monthly pharmacy refills. Whole blood was measured on dried blood spots. HIV-1 RNA was quantified and treatment failures were submitted for drug resistance testing. A remedial intervention was implemented in response to baseline testing. The primary outcome was viral load <5000 copies/mL. The two study rounds took place in 2011-2013.ResultsAmong eligible adults, 86% (73/85) of refugees and 84% (86/102) of Kenyan host nationals participated in the Round One survey; 60% (44/73) and 58% (50/86) of Round One participants were recruited for Round Two follow-up viral load testing. In Round One, refugees were older than host nationals (median age 36 years, interquartile range, IQR 31, 41 vs 32 years, IQR 27, 38); the groups had similar time on ART (median 147 weeks, IQR 38, 64 vs 139 weeks, IQR 39, 225). There was weak evidence for a difference in the proportion of refugees and host nationals who were virologically suppressed (<5000 copies/mL) after 25 weeks on ART (58% vs 43%, p = 0.10) and no difference in the proportions suppressed at Round Two (74% vs 70%, p = 0.66). Mean adherence within each group in Round One was similar. Refugee status was not associated with viral suppression in multivariable analysis (adjusted odds ratio: 1.69, 95% CI 0.79, 3.57; p = 0.17). Among those not suppressed at either timepoint, 69% (9/13) exhibited resistance mutations.ConclusionsVirologic outcomes among refugees and host nationals were similar but unacceptably low. Slight improvements were observed after a remedial intervention. Virologic monitoring was important for identifying an underperforming ART program in a remote facility that serves refugees alongside host nationals. This work highlights the importance of careful laboratory monitoring of vulnerable populations accessing ART in remote settings.Electronic supplementary materialThe online version of this article (doi:10.1186/s13031-017-0111-3) contains supplementary material, which is available to authorized users.

Unified European support framework to sustain the HIV cascade of care for people living with HIV including in displaced populations of war-struck Ukraine

“…Provide ART to patients [43][44][45][46][47] A proper assessment of current and near-future available resources; clinical HIV severity assessment by WHO staging; ART triage by clinical severity if there is a scarcity of supply; increase links to care of identified people with HIV by creating communication means adapted to personal preferences, including by providing mobile phones; setup of multidisciplinary mobile teams for ART provision with doctors, nurses, psychological health-care providers, social workers, and peer-to-peer support, equipped with point-of-care molecular tests (eg, PCR for HIV viral load, hepatitis, and tuberculosis), and emergency HIV care in displaced communities or people stuck in warfare, and operating within the existing mobile teams network of the Alliance of Public Health; health-care providers available with experience prescribing ART or with access to a professional HIV network or guidelines; facilitate the integration of people with HIV into health-care systems in host countries and facilitate resource availability (ie, medication, foremost dolutegravir-based regimens including TLD)…”

“…Provide ART antenatally, perinatally, and postnatally 25,26 Identify and link patients to care; health-care providers experienced in HIV obstetric care and vertical transmission prevention with access to a professional HIV network or guidelines Management of AIDS Establish swift, safe, and targeted logistics for medication (eg, cotrimoxazole; and rifampicin, isoniazid, pyrazinamide, and ethambutol) 35,24 Solid communication lines within, and support of, professional HIV networks (eg, online consultation for complex cases); use of professional HIV networks and associated support initiatives for expertise and infrastructure (eg, EACS's aware.hiv Ukraine initiative, 36 and ECEE's ART for Ukrainians abroad initiative 37 ); proper assessment of current and near-future available resources; medication triage by clinical severity if there is a scarcity of medication Free access to health-care services to help in the early detection of opportunistic infections 24,26 Resources (clinics and medication) available; appropriate liberal governmental health-care regulations and swift policy implementation Identify patients in need and allocation of AIDS medication 46 Registration of patients with AIDS; identifying AIDS by clinical assessment; health-care providers available with experience in managing AIDS or with access to a professional HIV network or guidelines…”

“…10,62 Convincing evidence exists that adequate HIV treatment and linkage to care programmes are effective during war, and HIV networks should support implementing these initiatives, regardless of the local situation. [43][44][45][46][47] To help with this core aspect of HIV care, EACS published a statement on HIV care shortly after the full-scale invasion of Ukraine started, helping to create a unified response and sense of urgency in Europe. 68 In response, the YING network initiated the support programme named aware.hiv Ukraine (Dare to Share Care) to further engage HIV care providers and scientific and community organisations throughout Europe to offer medical support, and to help medically and financially.…”

“…10,46,35 Drug resistance testing in people with HIV without viral suppression on ART; trained operators and rapid, point-of-care molecular tests present in clinics; resources to test available (Table continues on next page) Tuberculosis surveillance and provision of Directly Observed Therapy in clinics or mobile teams for remote areas; overcome stigma and practical barriers (foremost for migrants and displaced people) by outreach work and awareness raising; free testing; resources (point-ofcare tests) available PrEP, PEP, STI prevention, and birth control…”

Clinical outcomes of a cohort of migrants and citizens living with human immunodeficiency virus in Botswana: implications for Joint United Nation Program on HIV and AIDS 90-90-90 targets

“…In our study, viral suppression was significantly higher in citizens (73%) than migrants (66%); a study in Kenya found similar, unacceptably low viral suppression rates in refugees and host nationals (74% and 70%; P = .66). [33]…”