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 bednets 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 0.5 log10 1.0 log10 increase increase increase Increase in likelihood of heterosexual 18-20% 26-40% 100% transmission Increase in risk of progression 24-25% 44% 113% to AIDS or deathIntro Background Malaria Helminths Implications Conclusions
Effect of modest VL reduction Gupta et al. JID 2007; 195 (Feb 15).Intro Background Malaria Helminths Implications Conclusions
Study ObjectivesPRIMARY: To determine whether the provision of a longlasting insecticide-treated bed net (LLIN) and a point-of-care water filtration device to HIV-1 infected ART-naïveadults in Kenya delays HIV-1 disease progression, asmeasured by time to CD4 count <350 cells/mm3 and/ordeath.SECONDARY: To determine the effect of LLIN and asimple microbiological water purification system on theincidence of malaria and reported diarrheal disease whenadded to the standard regimen of TMP/SMX amongantiretroviral 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)
Use of Intervention Water purification methods and use of bed nets during study follow-up between cohorts Intervention Control N= 361 N= 127* 1 1 1 Est. % Est. % p-value 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!
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 Kaplan-Meier plot of time to disease progression by cohort: Time to CD4<350 1.00 0.75 Probability 0.50 0.25 Control Intervention 0.00 0 .5 1 1.5 2 Ti me From Enroll ment, YearsNumber at risk (Ev ents) Control 228 (32) 195 (39) 150 (19) 107 (9) 52 (8) Interv ention 361 (28) 327 (60) 259 (34) 149 (13) 52 (0)
Impact on HIV-1 Disease ProgressionKaplan-Meier plot of time to disease progression by cohort: Time to CD4<350 or Death 1.00 0.75 Probability 0.50 0.25 Control Intervention 0.00 0 .5 1 1.5 2 T i me From Enroll ment, Years N um ber at ris k (Ev ent s) C ontrol 228 (32) 195 (40) 150 (21) 107 (9) 52 (8) I nt erv ention 361 (30) 327 (61) 259 (35) 149 (14) 52 (0)
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