Hindawi Publishing Corporation
AIDS Research and Treatment
Volume 2012, Article ID 412643, 8 pages
AchievingUniversal AccessforHuman ImmunodeficiencyVirus
andTuberculosis:Potential PreventionImpact of anIntegrated
Multi-Disease Prevention CampaigninKenya
Reuben Granich,1Nicolas Muraguri,2AlexandreDoyen,3
1Treatment and Care Unit, Department of HIV/AIDS, World Health Organization, Avenue Appia 20,
1211 Geneva, Switzerland
2Ministry of Public Health and Sanitation, Government of Kenya, Nairobi, Kenya
3Vestergaard Frandsen (EA) Ltd., Waiyaki Way, ABC Place, P.O. Box 66889, Nairobi 00800, Kenya
4Innovation Centre, Vestergaard Frandsen, Chemin de Messidor 5-7, 1006 Lausanne, Switzerland
5South African Centre for Epidemiological Modeling and Analysis, Stellenbosch, South Africa
Correspondence should be addressed to Reuben Granich, firstname.lastname@example.org
Received 30 November 2011; Revised 27 January 2012; Accepted 28 January 2012
Academic Editor: Anthony Harries
Copyright © 2012 Reuben Granich et al. This is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly
In 2009, Government of Kenya with key stakeholders implemented an integrated multi-disease prevention campaign for water-
and counseling (HTC), condoms, long-lasting insecticide-treated bednets, and water filters. People with HIV were offered on-site
CD4 cell counts, condoms, co-trimoxazole, and HIV clinic referral. We analysed the CD4 distributions from a district hospital
cohort, campaign participants and from the 2007 Kenya Aids Indicator Survey (KAIS). Of the 5198 individuals participating in the
campaign, all received HTC, 329 (6.3%) tested positive, and 255 (5%) were newly diagnosed (median CD4 cell count 536cells/µL).
The hospital cohort and KAIS results included 1,284 initial CD4 counts (median 348/L) and 306 initial CD4 counts (median
550/µL), respectively (campaign and KAIS CD4 distributions P = 0.346; hospital cohort distribution was lower P < 0.001 and
P < 0.001). A Nyanza Province campaign strategy including ART <350 CD4 cell count could avert approximately 35,000 HIV
infections and 1,240 TB cases annually. Community-based integrated public health campaigns could be a potential solution to
reach universal access and Millennium Development Goals.
In 30 years since the start of the human immunodeficiency
virus (HIV) pandemic over 25 million people have died
[1, 2]. In 2010, an estimated 34 million people were living
with HIV and 67% of them lived in sub-Saharan Africa .
Antiretroviral therapy (ART) has considerable potential to
save lives while reducing the HIV transmission [4–7]. By
the end of 2010, 6.6 million people were on antiretroviral
treatment (ART) in the world . Despite this remarkable
achievement, an estimated 7.5 million people with CD4 cell
counts <350/µL were still in need of treatment . With-
out a dramatic reduction in HIV incidence it is unlikely
that we will be able to meet the growing demand for ART
[3, 8]. Addressing this prevention gap will require innovative
approaches to improving access to HIV services including
HIV testing and counselling (HTC) and ART.
Community-based efforts, including outreach beyond
health facilities, may provide one approach to help bridge
this gap. Of the 34 million people living with HIV, a majority
are still unaware of their HIV status . WHO, recognizing
the need to markedly scale-up access to HTC, has recom-
mended provider initiated HIV testing and counselling .
an HTC target of 18 million (80%) of people 15–49 years
of age to be newly tested by 2013; however, despite increases
2 AIDS Research and Treatment
in facility-based HTC the 2007 Kenya Aids Indicator Survey
(KAIS) found that only 36% of adults have ever had an HIV
test, and less than 20% of HIV-infected adults know that
they are infected [10, 11]. Obstacles to access to HTC include
a shortage of trained counsellors, limited services, high
transportation costs, limited test kit availability, and stigma
[10–15]. Home-based HTC offers an important potential
strategy to reach targets by expanding access beyond health
care facilities. With a reported uptake of up to 90% in some
settings, home-based HTC also provides an opportunity for
couples counselling and mutual disclosure . In Uganda’s
Bushenyi District, a 2.5 year multi-disease house-to-house
acceptance) people in 92,984 (63%) households .
Although home-based service delivery is feasible in many
settings, it can be time and labour-intensive. Complemen-
tary community-based health campaigns are well suited to
delivering services to the rural poor and have been used to
deliver HIV counselling and testing and other simple inter-
ventions to large populations [16, 17]. By combining mul-
tiple interventions and placing a larger proportion of the
transaction costs onto the provider, integrated multi-disease
campaigns create efficiencies for both the consumer and
provider [16–19]. There is considerable experience with the
insecticide-treated bednets which have quickly reached high
coverage levels at low cost and are associated with declines
in child and adult mortality in east Africa [16–19]. More
recent work in sub-Saharan Africa has focused on bundling
multiple interventions into a multi-disease prevention pack-
age which includes long-lasting impregnated bednets, water
purification systems, preventive health education, condoms,
and cotrimoxazole prophylaxis for HIV-infected adults [16,
Building on the previous community-based campaign
experience in Kenya’s Kakamega District, in 2009 we imple-
mented a similar multi-disease prevention (MDP) campaign
in Kisii District, Nyanza Province . We applied lessons
learned to pilot streamlined HTC protocols, provide same-
day, onsite access to CD4 cell counts, and strengthen linkage
to care. Our study examines the HIV component of the Kisii
District campaign and compares CD4 count distributions to
explore whether a multi-disease campaign strategy can im-
prove earlier access to HIV diagnosis and treatment. We also
project the potential HIV and TB prevention impact achiev-
ed by reaching people earlier for different ART eligibility
2.1. Multi-Disease Prevention Campaign. In 2008 the Min-
istry of Health Kenya, the United States Government Centers
(a local NGO), and Vestergaard Frandsen (a private sector
manufacturing company focused on products that address
the MDGs) implemented a 7 day multi-disease prevention
campaign that reached 47,311 (92%) of adults 15–49 years
old in Kakamega District, Western Province of Kenya. The
campaign was in line with the Kenyan National AIDS
provided interventions to address HIV, malaria, and diar-
rhea [10, 16]. Point-of-care CD4 counts were also piloted in
selected sites . Nyanza Province in western Kenya, has
a high incidence of malaria, diarrhoeal disease, and tuber-
culosis [3, 10, 11, 23–25]. In 2007, an estimated 15% of 15–
to the high annual TB incidence (353 per 100,000 popula-
tion) [11, 24, 25]. Standard operating procedures from the
Campaign as described below.
In September 2009 we implemented a three-day multi-
disease prevention campaign that targeted diarrhoeal dis-
eases, malaria and HIV in Kisii District, Nyanza Province
(population 4,392,000). Three peri-urban campaign sites
were set up around health facilities in the periphery of Kisii
(Figure 1 map). The campaign was designed to (1) apply
lessons learned from previous campaigns to a peri-urban
setting, (2) pilot improved HIV testing and counselling pro-
tocols, (3) strengthen the referral system for improved link-
age to care, (4) determine the feasibility of providing same
day CD4 cell count testing for all HIV-positive participants
and, (5) explore the potential impact of campaigns for early
identification for HIV prevention and care services, and (6)
examine differences between campaign, hospital, and provi-
The campaign was planned to provide services for 5000
adults within 3 days by using a specific protocol adapted to
mass campaign settings. We conducted the campaign over a
weekend (Saturday, Sunday, and Monday) to ensure maxi-
mum participation of both men and women and limit dis-
ruptions to routine services. A pre-campaign social mobi-
lization exercise started one month before the start date and
engaged the community using village “baraza” forums with
local chiefs, radio and print messaging, and town cries with
mobile trucks. Participants were informed about campaign
services, campaign sites and provided health education
messages around diarrhea, malaria, HIV, and STDs. They
sus lists from 2008, identification cards, and indelible finger
print dye were used to ensure that participants could only
participate once in the campaign (all participants received
finger dye irrespective of the services accessed or serostatus).
diate local area, we used village elders and government offi-
carefully recorded location information during the registra-
A total of 90 counselors were hired and trained to use
the mass testing protocol designed for community-based
campaigns with a target of 25 clients per day. Pretest coun-
selling was offered by trained Health Communication Offi-
cers to groups of 20 participants selected for age and gender
as they waited to meet the HTC counsellors. Confidentiality,
consent, and counselling were assured by issuance of cards
with a unique identifier number during the registration
process and it was emphasized to all participants that HTC
was entirely voluntary and that everyone would receive the
other interventions whether or not they opted for HIV
AIDS Research and Treatment3
testing. HTC was provided on an “opt-in” basis and written
by the use of certified counsellors, refresher training courses,
a supervision system which employed one supervisor for
every 10 counsellors, sending 1 out of 50 blood samples for
reconfirmation with a different diagnostic method (PCR),
and exit interviews by trained staff for all campaign partic-
ipants. The exit interviews were used to assure quality and to
improve services on a real-time basis.
Participants who tested HIV positive received a 3-
care, and were offered enrolment in a support network by
peer counsellors. Linkage to care was given a high priori-
ty and planned for through various interventions. Coun-
selors emphasized the importance of care during post-test
counselling. Members from local people living with HIV
(PLWHA) support networks were enrolled and trained for
the implementation of the PLWHA navigator approach. As
part of the navigator strategy, people testing HIV positive
were offered further counselling by assigned PLWHA coun-
sellors and, with consent, were enrolled into local support
groups. Most participants opted to allow follow-up visits
and provided name, address, unique identifier number, and
phone number. PLWHA counsellors, using a list of clients,
checked in with health centers on a monthly basis and, if
necessary, made follow-up household visits .
The Kisii campaign included provision of one long-last-
ing insecticide-treated net per participant, water filters (indi-
vidual filter for men, household filter for women), 60 con-
doms per person, and health education encompassing HIV,
sexually transmitted infections, malaria, and water-borne
diseases. The unit cost per person by disease was $6.27 for
malaria (nets and training), $15.80 for diarrhea (filters and
and CD4 testing) [16, 27]. Using logistic and expenditure
data from the 2008 Lurambi District Campaign,  the
reliance on local managers, potential efficiencies of scale, and
other adjustments (Jim Kahn, personal communication).
The SUR cost of $31.98 per person included 67% for com-
2.2. Measurement and Analysis of CD4 Cell Count Distribu-
tions. AbsoluteCD4 cellcountsand totallymphocytecounts
were performed by portable Guava AUTOCD4 flow cytome-
capacity). Samples were processed in batches and had a 45-
minute incubation time and 4-minute processing time. Each
unit had a trained machine operator and a trained nurse or
other health care provider responsible for drawing 10µL of
whole blood (EDTA) and preparing samples for analysis. As
patients waited for their results, they were given additional
psychosocial counselling by a counsellor living with HIV. For
external quality control, 5 percent of all blood samples were
sent for confirmation at Kisii Level 5 Hospital Laboratory
using a Becton Dickinson Facs Calibur Flow Cytometer.
The Kisii Hospital laboratory routinely sends 10% of blood
samples to CDC Kisumu for external quality control.
To create a matching historical cohort and a baseline for
first measured CD4 count, for all newly diagnosed patients
aged 15 and above from March to August 2009 at the
HIV/AIDS Patient Support Center in the Kisi District Level
5 Hospital (apex of district health care facilities). All CD4
Level 5 Hospital laboratory Becton Dickinson Facs Calibur
We analyzed the CD4 data from the Kisii campaign, the
reference hospital and Nyanza province data from the re-
national population-based survey of Kenya that obtained
representative estimates on behavioral, clinical and biologic
indicators for HIV/AIDS. The 2007 KAIS was conducted
among a sample of households selected from all eight pro-
vinces in the country, covering both rural and urban areas
(more detailed methods are described in detail elsewhere)
4 AIDS Research and Treatment
Province (red; KAIS survey) and the Kisii Hospital cohort (blue).
The data for the hospital cohort are scaled to match the KAIS
data for the lowest CD4 cell count range and the differences in the
heights of the bars for the higher ranges show the proportion that
are missed in the hospital cohort.
2.3. Projecting the Potential HIV and TB Prevention Impact
of Early Detection. For our comparison and projections we
used data from those who were reported as being newly
diagnosed—all were assumed to be ART naive. Cumulative
distribution functions were compared using the standard
Kolmogorov-Smirnov test. We estimated the potential ben-
efits of early identification and starting ART for three
scenarios (1) <250 CD4 cells (status quo), (2) <350 CD4
cells, and (3) immediate ART irrespective of CD4 cell count.
To estimate the proportion of people with CD4 cell
counts that are missed under passive clinic-based case-find-
ing but would be found using a campaign approach, we
assumed that everyone with a CD4 cell count below 250/µL
will present to a health facility before they die. We scaled the
proportions in the “hospital reference” data so as to match
the proportion in the KAIS data set below 250/µL (Figure 2).
Applying the scaling proportion allows us to see the differ-
ences in proportions of people that are missing in the hos-
pital cohort at the higher CD4 levels. This in turn enables
us to obtain an approximate estimate of the increase in the
number of people who would be put onto ART and the
The population of Nyanza province is 4.4 million of
whom 2.9 million are adults with around 435,000 (15%)
who are estimated to be HIV positive . We estimated
the number of HIV-positive TB patients in Nyanza Province
in two ways. First, the case-notification rate of HIV-positive
TB patients in Nyanza is 189 per 100,000 population giving
risk of TB for those not receiving ART has been estimated to
be 13% . With a mean life expectancy of HIV-positive
people of ten years, this means that the annual risk of TB-
disease is 1.3% and we expect there to be about 435,000
× 0.013 = 5655 case of TB in HIV-positive people in the
the expected number is 6,985 per year. ART reduces the
ART immediately they were found to be HIV-positive the
number of TB cases averted would be 4,959. This enables us
to estimate the reduction in the number of TB cases that we
To estimate the number of new HIV transmissions
averted, we assumed that the epidemic is in a steady state so
that each person with HIV infects one other person before
they die. Assuming that the CD4 cell count is 750/µL imme-
diately after seroconversion  we multiply the number
started on ART by the proportion of time for which they are
on ART (the CD4 cell count at the time at diagnosis in the
different scenarios is used to calculate the amount of time
on and off ART). To derive the HIV infections averted we
compared the projected outcome using these assumptions
with “no ART.” To simplify the analysis, we did not include
in TB transmission and treatment of identified TB cases. We
also did not factor in WHO recommended IPT or infection
control for TB which is not yet in widespread use in Kenya
The study protocol was reviewed by the Kenya Ministry
of Public Health and Sanitation and considered to be part
of on-going program monitoring and evaluation. The study
represented a private-public partnership and funding for the
study was provided by the Kenya Ministry of Public Health
as part of routine public health services. Ministry of Health
Kenya and Vestergaard Frandsen funded the campaign;
MOH provided campaign personnel, HIV test kits, and
condoms. The decision to conduct, analyse, and submit the
study was taken by the Ministry of Health and WHO.
3.1. Multi-Disease Prevention Campaign. Over a three-day
period, the campaign reached 5198 individuals aged over 15
years with a 100% uptake of the HIV counselling and testing
and multi-disease preventive package. Counselors worked
8 hour days starting from 8:00 AM and tested around 25
clients per day (100% of target). Clients who were found to
be HIV negative were provided HTC in about 20 minutes,
while those who were diagnosed with HIV were given HTC
counseling in about 38 minutes. The process from drawing
blood to getting CD4 cell count results usually took around
two hours (mean 119; range 47–191 minutes).
Of the 5198, 2090 (40%) were males. Of the 329
participants who tested HIV positive, 71 (22%) were males;
HIV prevalence among males was 3.3% and 8.3% for
females. This difference of HIV prevalence between genders
reflects the 2010 antenatal care sentinel surveillance results
of 8.7% among women in Kisii District sites . A separate
study that included a subsample of the people from the Kisii
campaign and others evaluated factors affecting linkage to
care and found that 81% of people who consented to follow-
up visited the referral clinic by 10 months after the campaign
AIDS Research and Treatment5
Table 1: CD 4 values from the campaign, hospital reference, and
KAIS data sets. The table gives N, the number of people for whom a
CD4 cell count was done, the median CD4 cell count, and the pro-
portion of those tested that are below 250, 350, and 500cells/µL.
set is significantly different from the other two (P < 0.001 in both
cases) but the Campaign and KAIS data sets are not significantly
different (P = 0.346).
Campaign Hospital reference
N < 250 33 (13%)
N < 350 64 (25%)
N < 500 112 (44%)
N < 750 187 (74%)
N < 1000 228 (90%)
3.2. Analysis of CD4 Cell Count Distributions. Of the 258
(4.9%) who were newly diagnosed with HIV (71 knew their
status before campaign), CD4 count determination was per-
formed for 255 (98%). The median CD4 count was
536cells/µL (IQR 348 to 760;) with 13% having a CD4
count <250cell/µL and 25% a CD4 cell count <350cells/µL
Of the 1284 patients in the Kisii Hospital reference
cohort, 350 (27%) were male (age range 15–61; CD4 count
range 1–1862) and 934 (73%) were female (age range 15–69;
CD4 count range 1–2560). The first CD4 counts from the
1284 patients had a median of 348 (IQR 185 to 551) with
34% having a CD4 count <250 cell/µL and 50% a CD4 cell
count <350cells/µL (Table 1).
The results obtained from the 2007 KAIS data base for
Nyanza Province included 1585 females, 1386 (87%) tested,
240 (17%) HIV positive, 218 (91%) not on ART, and 203
(85%) with CD4 counts. Of the 1229 males surveyed, 994
(81%) were tested, 123 (12%) HIV positive, 108 (88%) not
on ART, and 103 (95%) with CD4 counts. The median CD4
count overall was 550cells/µL (IQR 305 to 785). Table 1
shows that the CD4 cell count data from the campaign for
Kisii are not significantly different from the KAIS data for
Nyanza (P = 0.346).
3.3. Projecting HIV and TB Prevention Impact of Early Detec-
tion. Figure 2 shows that the Hospital reference cohort has
significantly lower median CD4 cell counts when compared
with the Campaign and KAIS data. Table 2 shows that using
ourscaledestimation approachwitheithercampaign orhos-
pital-based strategies, current ≤250 ART eligibility criteria
results in around 38,000 people started on ART and about
645 cases of TB will be averted in Nyanza Province. Increas-
ing the CD4 cell count eligibility to ≤350 combined with
ing ART to 56,000, averts 26,000 new HIV infections, and
teria combined with the campaign approach would translate
into an estimated 74,000 people starting ART, thereby
averting 35,000 new HIV infections and preventing 1,240 TB
cases per year. Starting at a CD4 cell count of 500/µL gives
an even greater relative advantage to the campaign approach
with 129,000, or 2.6 times as many people started on ART,
and 2,182 total or 2.6 times as many TB cases averted using
the campaign approach when compared with the passive
reached over five thousand people in Kisii district including
over 200 people who were unaware that they were living with
HIV. The uptake of HCT in the campaign is comparable
to the high rates of over 90% observed in home-based,
door-to-door testing interventions implemented in Uganda
[15, 32, 33] and Kenya  and was achieved in considerably
less time. Similar to previous campaigns,  successful
implementation of this campaign may have been due to
the engagement of the community leadership, delivery of
the multi-disease prevention approach which included con-
Although access to laboratory tests including CD4 levels has
campaign successfully delivered same-day CD4 level testing
results for all of the newly identified people with HIV.
Delayed diagnosis and access to ART have significant
public health implications for both the individual and the
community. Expanded access to HCT linked with point-of-
care CD4 testing has considerable potential to support the
implementation of WHO’s recommendation to start ART
for everyone with a CD4 ≤ 350/µL . Comparison of
CD4 counts from campaign participants with the hospital
cohort CD4 data and the recent national survey suggests that
the campaign identified people significantly earlier in the
course of their HIV disease. This makes intuitive sense as it
reachespeople beforetheyaresymptomatic and is supported
by other studies examining the use of community-based
services outside health facilities . Although we do not
present the data, the 80% linkage to care for people diag-
nosed with HIV in this campaign at 10 months was better
than in many other settings  but required setting up a
robust follow-up system. The data also suggest that increas-
ing the threshold to 350/µL combined with the standard pas-
sive facility-based case-finding approach could increase the
number of people in Nyanza who need to start ART by a fac-
tor of 1.9 or 56,000 people. However, the campaign approach
combined with optimal linkage to care could increase the
number receiving ART by a factor of 3.7 or 74,000 additional
people—an additional 18,000 people who were unaware of
their HIV status and who were eligible but not on ART. Our
suggest that an active campaign approach to identify those
with CD4 cell count <350 could prevent 10,000 HIV trans-
more complex projections for the province and country are
beyond the scope of this paper, improving access to early
6AIDS Research and Treatment
Table 2: Projected prevention impact of campaign approach by CD4 eligibility criteria for Nyanza Province.
Campaign approach Passive case-finding
CD4 cell count
at start of
started on ART
averted per year
ART through a campaign approach could have significant
public health and economic benefits including preventing
morbidity, mortality, disease transmission, and reducing
costs to the individual, health system, and society [4, 6, 40].
Short intense multi-disease campaigns face a number of
challenges including maintaining efficiency and quality of
service provision and linkage to care while dealing with large
numbers of people. Previous work in Kenya and elsewhere
suggests that careful consensus building and micro-planning
with community leaders and key health care providers is
required to mobilize resources and provide high-quality ser-
vicesforthetemporary surgeof participants in thecampaign
. The various TB and HIV prevention scenarios modeled
would only be achievable under conditions of a high linkage
to care after the campaign which requires postcampaign
systems monitoring health care facility attendance, active
followup, and local support networks. Another significant
challenge is the cost of the campaign. Preliminary analyses
suggest that despite the relative high costs per person 
the campaign is likely to be cost effective in part due to the
multi-disease approach and the numbers of people reached
in a short period of time. Arguably, delivering health care
services from fixed facilities is also costly and often does not
reach stated objectives.
There are important limitations to our study. The com-
parison of the hospital, province, and campaign CD4 data
may have been influenced by a number of biases introduced
from the selection of the three populations. Specifically, it is
difficult to say with certainty that the three subpopulations
that we compared are similar given the different ways that
people accessed the hospital, campaign and KAIS survey
(e.g., nonresponse, refusal, and missing CD4 counts). Addi-
tionally, there are potential confounders that may have
affected the CD4 results including the difference in methods
sis, and viral infections. However, the similarity of the cam-
paign data with the provincial data for Nyanza is reassuring
and the lower CD4 counts of those who are ill and seeking
care in a hospital setting make sense. Our assumption that
people coming into the hospital for care were not referred
from a peripheral site and the high linkage to care may
strategy. However, despite our lack of certainty regarding the
projected benefits which relied on crude estimates, we are
likely to be directionally correct and a more sophisticated
modeling approach may provide additional insights.
We are far from achieving universal access and there is
increasing interest in new approaches to ensuring early and
equitable access to ART and other HIV services. This multi-
disease prevention campaign presents an operational proof
of concept for the expanded access to HTC and same-day
CD4 testing that is required for many countries to reach
national HIV and TB prevention goals. Multi-disease inte-
sent an important conceptual breakthrough in our efforts
to achieve national health objectives reflected in the Millen-
nium Development Goals .
R. Granich is the Lead Author. R. Granich, N. Muraguri, A.
Doyen, N. Garg, and B. Williams made the study design; N.
Muraguri, A. Doyen, and N. Garg were responsible for the
collection of data; B. Williams, A. Doyen, and R. Granich
made the analysis; R. Granich, N. Muraguri, A. Doyen, N.
Muraguri, and B. Williams were responsible for interpreta-
tion of data; R. Granich, N. Muraguri, A. Doyen, N. Garg,
and B. Williams made the draft paper; R. Granich, N. Mura-
guri, A. Doyen, N. Muraguri, and B. Williams prepared the
thors and do not represent the official policy, endorsement,
or views of the World Health Organization.
Conflict of Interests
None of the authors has conflict of interests to declare.
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