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Importance: From 2004 to 2014, the US President’s Emergency Plan for AIDS Relief (PEPFAR) invested more than $248 000 000 in the prevention of mother-to-child transmission (PMTCT) of HIV in Kenya. Concurrently, child mortality in Kenya decreased by half. Objective: To identify the extent to which the decrease in child mortality in Kenya is associated with PEPFAR funding for PMTCT of HIV. Design, Setting, and Participants: This population-based survey study conducted in Kenya estimated the association between annual per capita PEPFAR funding for PMTCT (annual PCF) and cumulative per capita PEPFAR funding for PMTCT (cumulative PCF), extracted using 2004-2014 country operational reports as well as individual-level health outcomes, extracted from the 2003, 2008-2009, and 2014 Kenya Demographic and Health Surveys and the 2007 and 2012 Kenya AIDS Indicator Surveys. The study included children of female respondents to the 2003, 2008-2009, and 2014 Kenya Demographic and Health Surveys who were born 1 to 60 months (for neonatal mortality) or 12 to 60 months (for infant mortality) before the survey, as well as female respondents who had recently given birth and reported on HIV testing during antenatal care (ANC) during the 2007-2014 surveys. Results were adjusted for year, province, and survey respondent characteristics. Statistical analysis was performed from July 8, 2016, to December 10, 2018. Main Outcomes and Measures: Neonatal mortality was defined as death within the first month of life and infant mortality was defined as death within the first year of life. HIV testing during ANC was defined as receiving counseling on PMTCT, undergoing an HIV test, and receiving test results during ANC. Results: The analysis included 33 181 neonates (16 870 boys), 26 876 infants (13 679 boys), and 20 775 mothers (mean [SD] age, 28.0 [6.7] years). PEPFAR funding was not associated with neonatal mortality. A $0.33 increase in annual PCF, corresponding to the difference between the 75th and 25th (interquartile range) percentiles of funding, was significantly associated with a 16% (95% CI, 4%-27%) reduction in infant mortality after a 1-year lag. A 14% to 16% reduction persisted after 2- and 3-year lags, and comparable reductions were observed for unlagged and 1-year lagged cumulative PCF. An increase of 1 interquartile range in cumulative PCF was associated with a 7% (95% CI, 3%-11%) increase in HIV testing during ANC, which intensified with subsequent lags. Between 2004 and 2014, sustained funding levels of $0.33 annual PCF could have averted 118 039 to 273 924 infant deaths. Conclusions and Relevance: Evidence from publicly available data suggests that PEPFAR’s PMTCT funding was associated with a reduction in infant mortality and an increase in HIV testing during ANC in Kenya. The full outcome of funding may not be realized until several years after allocation.
Health outcome data came from the publicly available Kenya Demographic and Health Surveys and Kenya AIDS Indicator Surveys (KAIS), which use stratified 2-stage cluster random sampling to select nationally representative samples. Our analysis included data from the 5 most recent surveys: the 2003, 2008-2009, and 2014 Kenya Demographic and Health Surveys and the 2007 and 2012 KAIS.3,5,16,17,18 Neonatal mortality, defined as death within the first month of life, and infant mortality, defined as death within the first year of life, were assessed using female respondents’ birth histories from the 2003, 2008-2009, and 2014 surveys. For each live birth, mothers reported their child’s birth date, vital status, and death date, if applicable. Because maternal HIV is a common cause of maternal and infant death, birth histories can underestimate infant mortality in generalized HIV epidemics19; however, bias can be reduced by considering recent births.20 Therefore, neonatal mortality was assessed among children born 1 to 60 months prior to the interview date and infant mortality was assessed among children born 12 to 60 months prior to the interview date. Although the 2012 KAIS gathered data on abbreviated birth histories, we excluded it in our primary analysis because neonatal and infant mortality was not included in the final report of the survey (eAppendix and eTable 1 in the Supplement).3 Rates of HIV testing during ANC, which is one mechanism through which PMTCT programs can help prevent vertical transmission of HIV and subsequent child mortality, were measured among female respondents who had given birth within 5 years of the 2007, 2008-2009, and 2012 surveys and within 2 years of the 2014 survey and is defined as receiving counseling on PMTCT, undergoing an HIV test, and receiving test results during ANC. For women with multiple births, data on HIV testing during ANC were gathered for the most recent birth. Data on the independent variable, PEPFAR funding for PMTCT, were extracted from publicly available Country Operational Plans (COPs), which describe annual planned expenditures21 (eAppendix, eFigure 1, and eTable 2 in the Supplement). This research involved the collection and analysis of preexisting, publicly available, deidentified data and received an exemption for review from the Harvard T.H. Chan School of Public Health Institutional Review Board and a “not research” designation from the US Army Medical Research and Materiel Command, Human Research Protection Office. The protocol was additionally reviewed and approved by the Kenya Medical Research Institute’s Scientific and Ethics Review Unit. This study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guidelines. Additional details on the sampling frame, response rates, and other ethical and methodological considerations for the Kenya Demographic and Health Surveys and KAIS can be found elsewhere.3,5,16,17,18 Statistical analysis was performed from July 8, 2016, to December 10, 2018. We assessed the association between the amount of per capita PEPFAR funding for PMTCT and health outcomes using regression models.22 For annual per capita funding (annual PCF), each individual’s exposure equaled the amount of PEPFAR funding allocated to their province of residence in their year of birth (or, for HIV testing during ANC, in the year they gave birth) divided by the province’s population.23 For cumulative per capita funding (cumulative PCF), each individual’s exposure to PEPFAR funding was calculated using the cumulative total of PEPFAR funding for PMTCT allocated to their province from the beginning of PEPFAR until their year of birth. We investigated 0- to 3-year lags between funding allocation and the time that funding was hypothesized to have effects (eTable 2 in the Supplement). Individuals residing in province-years without funding data were excluded from the primary analyses but were included in sensitivity analyses. We estimated risk ratios and 95% CIs associated with PEPFAR funding for PMTCT using weighted generalized estimating equations24 that created a representative sample across surveys and stepwise selection of restricted cubic splines that assessed for potential nonlinear associations between funding and health outcomes.25 All models treated individual birth as the unit of analysis and adjusted for province and controlled for calendar year using restricted cubic splines. To address confounding, we present both minimally adjusted models, which adjusted only for province and calendar year, and fully adjusted models, which included additional factors that were believed to be potentially important confounders that were known or potential risk factors for the outcomes. Fully adjusted models further controlled for household wealth quintile, water and sanitation access, urban vs rural status, mosquito net ownership, respondent educational level, ethnicity, religion, marital status, age, parity, and exposure to mass media, and, for neonatal and infant mortality, child’s sex, short interval preceding birth, and birth order rather than parity (eAppendix in the Supplement). To estimate the number of lives saved by PEPFAR funding for PMTCT, we used the 1-year lagged model to determine the number of infants who would have died between 2004 and 2014 under different levels of annual PCF (eAppendix in the Supplement). We evaluated the sensitivity of our results to missing exposure data by conducting analyses assuming that province-years with missing funding data received $0.04 in annual PCF (reflecting the minimum observed funding level), $0.23 in annual PCF (reflecting the 25th percentile of observed funding levels), $0.32 in annual PCF (reflecting the median of observed funding levels), $0.56 in annual PCF (reflecting the 75th percentile of observed funding levels), and $0.93 in annual PCF (reflecting the maximum observed funding level) and, for infant mortality, using inverse probability weighting (eAppendix in the Supplement).26 We also assessed whether the association between PEPFAR funding and infant mortality differed by maternal HIV status among the subset of infants with known maternal HIV status based on HIV testing conducted in the 2003 and 2008 surveys (eAppendix in the Supplement).
