The adult population impact of HIV care and antiretroviral therapy in a resource poor setting, 2003–2008

Objective:To describe the population uptake of HIV care including antiretroviral therapy (ART) and its impact on adult mortality in a rural area of western Kenya with high HIV prevalence during a period of rapid HIV services scale-up. Design:Adult medical chart data were abstracted at health facilities providing HIV care/ART to residents of a Health and Demographic Surveillance System (HDSS) and linked with HDSS demographic and mortality data. Methods:We evaluated secular trends in patient characteristics across enrollment years and estimated proportions of HIV-positive adult residents receiving care. We evaluated adult (18–64 years) population mortality trends using verbal autopsy findings. Results:From 2003 to 2008, 5421 HDSS-resident adults enrolled in HIV care; 61.4% (n = 3331) were linked to HDSS follow-up data. As the number of facilities expanded from 1 (2003) to 17 (2008), receipt of HIV services by HIV-positive residents increased from less than 1 to 29.5%, and ART coverage reached 64.0% of adults with CD4 cell count less than 250 cells/&mgr;l. The proportion of patients with WHO stage 4 at enrollment decreased from 20.4 to 1.9%, and CD4 cell count testing at enrollment increased from 1.0 to 53.4%. Population-level mortality rates for adults declined 34% for all causes, 26% for AIDS/tuberculosis, and 47% for other infectious diseases; noninfectious disease mortality rates remained constant. Conclusion:The initial years of rapid HIV service expansion coincided with a drop in adult mortality by a third. Continued expansion of population access to HIV clinical services, including ART, and program quality improvements will be necessary to achieve further progress in reducing HIV-related morbidity and mortality.