Department of Global Health Lecture Series Michael Chung November 25, 2008 'Notes from the Field: Practicing HIV Research in Kenya.'

1. Notes from the Field: Practicing HIV Research in Kenya Michael H. Chung, MD, MPH

10. AZT vs. NVP trial profile 2732 women offered testing 1865 (68%) accepted 319 (17%) HIV-1 positive women 76 (24%) enrolled 66 randomized 56 (85%) completed 6 week follow-up 30 NVP 30 AZT

11. Breast milk HIV-1 RNA over weeks postpartum 0.3 2.03 2.43 36 to 42 0.3 2.24 2.60 29 to 35 0.3 2.23 2.70 22 to 28 0.003 1.90 2.97 15 to 21 0.005 1.78 2.48 8 to 14 0.1 1.98 2.42 3 to 7 0.1 3.08 1.70 0 to 2 Median Median p-value Nevirapine AZT Days MEAN LOG COPIES/ML

12. Mean log HIV-1 RNA in breast milk over days postpartum

13. KM curves of HIV-1 infant infection

14. Transmitters (T) vs. nontransmitters (NT) mean log HIV-1 RNA in breast milk over days postpartum

15. KM curves of maximum breast milk log HIV-1 RNA viral level (BMVL) and nevirapine (NVP) on cumulative HIV-1 infant infection

17. HAART vs. AZT/NVP trial profile 162 HIV-1 positive women 76 eligible (47%) 58 randomized (76%) HAART 30 AZT/NVP 28 Month 1 26 Month 1 25 2 stillbirth 2 lost 1 stillbirth 2 lost

18. Breast milk HIV-1 RNA over weeks postpartum 0.04 3.34 1.84 > 28 0.05 2.61 1.95 22 to 28 0.1 2.22 1.88 15 to 21 0.2 2.10 1.81 8 to 14 0.8 1.92 1.95 3 to 7 0.05 2.87 1.88 0 to 2 Median Median p-value AZT/NVP HAART Days MEAN LOG COPIES/ML

19. Proportion of women with undetectable HIV-1 RNA in breast milk

23. Grace

24. Eunice

26. Getting HAART

27. After 1 year of HAART

29. Tumaini recipients

30. Coptic pharmacy

31. Hope Clinic ~ 2004

32. Harborview Medical Center

33. HAART Protocol Meet with CLINICIAN Talk about starting medications Meet with COUNSELOR Talk about the meds & why it is important to take them regularly, possible side effects, drugs interactions, etc. Meet with NUTRITIONIST Talk about the meds and their food requirements and how to use food to help control any of the side effects. Meet with SOCIAL WORKER Talk about things that could impact how you take your meds, including housing, finances, etc. Meet with CLINICIAN again Talk about your readiness to start meds and answer any remaining questions. If you are ready, prescriptions will be written. Meet with PHARMACIST Answer any questions about your medications and confirm your knowledge and acceptance. Pick up 2-week supply of meds.

35. Hope Centre ~ 2005

36. Hope Center enrollment

37. Hope Center for Infectious Diseases ~ 2008 ~

41. Hope patient catchment area Rift Valley Eastern Western Nyanza Central Coast Nairobi Embakasi (22%) Dagoretti (20%) Kasaran (19%) Kibera/Langata (15%) Starehe (6%) Westlands (7%) Makadara (6%) Kamukunji (3%) Nairobi Central Rift Valley Nyanza Eastern Coast Western

42. Retention among HAART eligible and initiating HAART

43. Retention compared to other clinics Percent of patients remaining in care Hope Center Other ARV programs in sub-Saharan Africa

45. Pill count over 18 months 0.01 78% 95% 85% 89% Median monthly adherence ≥ 95% p-value Control Counseling & Alarm Alarm Counseling

46. Plasma HIV-1 RNA over 18 months 0.2 5.7 5.6 5.6 5.8 Baseline Median plasma viral load (log 10 copies/ml) 0.5 1.8 1.8 1.8 1.9 Month 18 0.5 1.4 1.4 1.4 1.4 Month 12 0.8 1.4 1.4 1.4 1.4 Month 6 p-value Control Counseling & Alarm Alarm Counseling Month

47. CD4 count over 18 months 0.9 114 130 111 123 Baseline Median CD4 count (cells/ml) 0.9 348 328 323 340 Month 18 0.9 285 258 271 259 Month 12 0.9 246 234 288 289 Month 6 p-value Control Counseling & Alarm Alarm Counseling Month

53. UW courses in Kenya

54. Adobe Connect

55. UW fellows, residents, and students in Kenya