By Lazarus Momanyi, National AIDS and STI Control Programme (NASCOP), Ministry of Health, Kenya
Evidence shows high rates of disengagement of clients in their first year on antiretroviral treatment (ART). In 2021, the World Health Organization provided an updated treatment monitoring algorithm, recommending the first VL be obtained and the result reviewed by six months on ART supporting assessment and enrolment of clients with a suppressed viral load (VL) into DSD models six months after ART initiation. However, in most African countries, the first VL is taken only six months after starting ART delaying result review and assessment for DSD models to seven to nine months after treatment start. An earlier VL by month three may be beneficial for rapid identification of poor adherence, prevention of drug resistance and timely DSD enrolment of clients who are well.
In 2021, Kenya decided to update national guidance, shifting the first VL to month three to harmonize monitoring across all populations. The month three VL result is available for review during the clinical encounter at month six. The early integration of dolutegravir (DTG) as the preferred first-line agent in Kenya in 2017 provided the pharmacological foundation for this policy change.
Key lessons learnt from Kenya’s implementation of early VL testing were that an early VL is feasible and does not translate to additional VL requirements or costs. With most clients having transitioned to the more efficacious DTG-based ART, suppression rates are favourable, allowing for early transition to less-intense DSD. For the client, this reduces the intensity of clinical visits and associated costs and may enhance adherence and retention in the first year. Early access to efficacy of ART can support motivation for adherence and early U=U messaging. It can lower healthcare system costs by decongesting the facilities while allowing resources to be redistributed to clients with increased healthcare needs, including those with an unsuppressed VL. To further optimize the DSD interventions, additional healthcare worker support through mentorship is critical.
The revised Kenya Integrated Guidelines for HIV, STI and Viral Hepatitis 2026 (forthcoming) represent a strategic pivot toward a more resilient and person-centred HIV response, balancing high-quality clinical care with the realities of a shifting global funding landscape. The revised guidance also expands six-multi-month dispensing of ART and introduces an annual clinical review for clients established on ART. Kenya is further expanding access to VL testing by scaling innovative technologies, such as point-of-care and multiplexing platforms. There is ongoing support for healthcare workers to further scale person-centred models in integrated settings.
