Evaluation of Long-lasting Insectide-Treated Bed and Point-of-use Water Filter to Delay HIV-1 Disease Progression in Kenya

Evaluation of long-lasting insecticide-treated bed nets and a point-of-use water filter to delay HIV-1

disease progression in Kenya

Judd L Walson, MD, MPH Assistant Professor

Departments of Global Health, Medicine (Infectious Disease), Pediatrics and Epidemiology

University of Washington

0.3 log10 increase

0.5 log10 increase 1.0 log10 increase

Increase in likelihood of heterosexual transmission

18-20% 26-40% 100%

Increase in risk of

progression to AIDS or

death

24-25% 44% 113%

Intro Background Malaria Helminths Implications Conclusions

Gupta et al. JID 2007; 195 (Feb 15).

Effect of modest VL reduction

Intro Background Malaria Helminths Implications Conclusions

Study Objectives

PRIMARY: To determine whether the provision of a long lasting insecticide-treated bed net (LLIN) and a point-of-care water filtration device to HIV-1 infected ART-naïve adults in Kenya delays HIV-1 disease progression, as measured by time to CD4 count <350 cells/mm3 and/or death. SECONDARY: To determine the effect of LLIN and a simple microbiological water purification system on the incidence of malaria and reported diarrheal disease when added to the standard regimen of TMP/SMX among antiretroviral naïve, HIV infected adults in Kenya.

Study Recruitment and Eligibility

Recruitment Public health campaign in Western Kenya for VCT, which provided LLIN and water filter and HIV care and treatment clinics in Western Kenya (Kisii Provincial, Kisumu District Hospitals).

Inclusion Criteria •  18 years of age or older •  Confirmed HIV-1 infection •  ART naïve •  CD4 count >350 within previous 3 months •  WHO clinical stage I or II

Exclusion Criteria •  Pregnancy •  History of ART (self reported)

Recruitment Public health campaign in Western Kenya for VCT, which provided LLIN and water filter and HIV care and treatment clinics in Western Kenya (Kisii Provincial, Kisumu District Hospitals).

Inclusion Criteria •  18 years of age or older •  Confirmed HIV-1 infection •  ART naïve •  CD4 count >350 within previous 3 months •  WHO clinical stage I or II Exclusion Criteria •  Pregnancy •  History of ART (self reported)

Participation

Use of Intervention

Intervention N= 361 Est. %1

Control N= 127* Est. %1 p-value1

Water purification methods % who drink purified water: 99·5 76·0 < 0·001

Purification system:2

% who boil 9·0 29·9 < 0·001

% who use chlorine 5·7 45·4 < 0·001

% who use filter 93·0 0·4 < 0·001

Use of bed nets % who have a net: 97·7 83·1 < 0·001 % who both have a net and sleep under it: 97·3 82·4 < 0·001

!

Water purification methods and use of bed nets during study follow-up between cohorts

Impact on Diarrhea/Malaria

• The use of LLIN/Water Filter reduced self-reported diarrhea

(RR: 0·65; 95% CI: 0·45, 0·93)

• The use of LLIN/Water Filter reduced self-reported malaria

(RR: 0·75; 95% CI: 0·60, 0·93)

• The use of LLIN/Water Filter reduced clinically diagnosed malaria

(RR: 0·66; 95% CI: 0·49, 0·88)

Impact on HIV-1 Disease Progression

0.00

0.25

0.50

0.75

1.00

Prob

abilit

y

361 327(28) 259(60) 149(34) 52(13)Interv ention228 195(32) 150(39) 107(19) 52(9)Control

Number at risk (Ev ents)

0 .5 1 1.5 2Time From Enrollment, Years

ControlIntervention

(8)(0)

Kaplan-Meier plot of time to disease progression by cohort: Time to CD4<350

Impact on HIV-1 Disease Progression

0.00

0.25

0.50

0.75

1.00

Prob

abilit

y

361 327(30) 259(61) 149(35) 52(14)Interv ention228 195(32) 150(40) 107(21) 52(9)Control

Number at risk (Ev ents)

0 .5 1 1.5 2Time From Enrollment, Years

ControlIntervention

(8)(0)

Kaplan-Meier plot of time to disease progression by cohort: Time to CD4<350 or Death

Results

• The combined intervention resulted in a 27% risk reduction in

HIV disease progression, as measured by CD4 count ≤350

cells/mm3 (HR: 0·73; 95% CI: 0·57, 0·95). This difference

remained significant after adjusting for either toilet type or water

source (HR 0·75; 95% CI: 0·58, 0·97).

Acknowledgements

n  All the study participants n  University of Washington/KEMRI - Ben Piper, Grace John-

Stewart, Benson Singa, Paul Ndungu, Toney Odhiambo, King Holmes, Barbara Payne, Barbra Richardson, Margaret Barrett, Chris Kealy, Rekha Patel, Rowena de Saram, Laura Sangare, Krista Yuhas, Frankline Onchiri, Patricia Pavlinac, Barbra Richardson, Phelgona Otieno

n  The fantastic study staff in Nairobi n  The staff of all of the study sites n  KEMRI CCR – Dr. Bukusi, Dr. Rashid, Dr. Mpoke n  CDC –Jonathan Mermin, Becky Bunnell, Clement Zeh n  Vestergaard-Frandsen – Navneet Garg, Alexandre Doyen