In 2014, the Joint United Nations Programme on HIV/AIDS (UNAIDS) established the 90-90-90 target for the year 2020, the goal of which is for 90% of all people with HIV (PWH) to know their status; among those diagnosed, for 90% to be receiving antiretroviral therapy; and for 90% of treated individuals to achieve sustained viral suppression. Some countries struggled to reach these targets, and among countries that achieved the first step in the cascade of care outlined above, HIV testing is not evenly accessed among some demographic sub-groups.
In sub-Saharan Africa, HIV testing gaps persist in men and among key populations, including children and adolescents, people living in informal urban settlements, and vulnerable women. High proportions of a population who remain untreated for HIV infection, or who receive delayed treatment, remain at risk for onward transmission and impede progress toward meeting national and global HIV control goals. On an individual level, untreated HIV infection leads to poorer clinical outcomes and an increased risk of mortality. Now, in 2021, we set our eyes on the new UNAIDS targets, which seek to increase the levels of coverage in the HIV cascade of care to 95% by the year 2030. Ensuring that HIV testing is equally accessible to all, regardless of age, gender, or socioeconomic status, is a necessary first step toward reaching these goals, as well as toward achieving a just distribution of health and wellbeing among all global citizens.
This dissertation aims to quantify gaps in HIV testing and to identify effective testing strategies among three key populations in western Kenya: infants, children, and adolescents; residents of informal urban settlements; and vulnerable women living in an informal settlement, including widows and separated/divorced women.
Chapter 1 assesses the impacts of a large programmatic initiative implemented in 138 HIV care and treatment facilities in western Kenya, with the goal of increasing pediatric HIV testing and antiretroviral treatment. This analysis demonstrates that a suite of interventions, including family-based testing, text messaging, and community outreach, responded to gaps in HIV testing and increased identification of youth living with HIV in a resource-limited, high-incidence setting. Chapter 2 describes the implementation of a hybrid HIV testing approach in an informal urban settlement in western Kenya. This analysis found that the hybrid strategy was effective at reaching the 90% HIV testing target in an urban setting, at identifying previously-undiagnosed men and youth living with HIV, and at linking identified PWH to care and treatment. Using data from the same initiative, Chapter 3 explores differences in HIV testing behaviors and outcomes among women living in an informal urban settlement in western Kenya. This analysis found that widows and separated/divorced women living in an informal settlement are at increased risk of having a previously-unidentified HIV infection and poorer overall health, and that a multi-disease community health campaign was an effective strategy to engage them in HIV testing.
Findings from this dissertation highlight gaps and disparities in the progress toward HIV testing targets and may be used to inform strategies to further engage key populations in HIV testing, in order to equitably work toward control of the global HIV epidemic.
