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Abstract: A-641-0395-09770

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Abstract: A-641-0395-09770

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  1. Antiretroviral therapyeligibility at enrollment and time to treatment initiation in EthiopiaChloe A. Teasdale1, Chunhui Wang1, Sileshi Lulseged1, Tamrat Assefa1, Solomon Ahmed3, Zelalem Habtamu4, Matthew R. Lamb1, Zenebe Melaku1, Elaine J. Abrams1for the Identifying Optimal Models of HIV Care in Africa study1ICAP-Columbia University, Mailman School of Public Health, New York, USA; 2Centers for Disease Control and Prevention, Addis Ababa, Ethiopia; 3Oromia Regional Health Board, Ethiopia Ministry of Health, Oromia, Ethiopia This research supported by PEPFAR through the US Centers for Disease Control and Prevention under the terms of Cooperative Agreement Number 5U62PS223540 and 5U2GPS001537 Abstract: A-641-0395-09770

  2. Background (1) • 11.7 million adults and children received ART in low and middle income countries in 20131 • Over 7.5 million patients on treatment in sub-Saharan Africa • Timely initiation of ART is critical before advanced clinical or immunologic disease status reached • Late ART initiation associated with increase risk of opportunistic infections and mortality2 • WHO treatment guidelines raised CD4 eligibility criteria in 2010 and 2013 to maximize treatment benefits3 1UNAIDS 2013; 2SMART 2008, When to Start 2009, Severe 2010;3WHO 2013

  3. Background (2) Routine monitoring ART initiation ART eligibility assessment HIVTesting Linkage to HIV care Pre-ART Pre-ART Not eligible ART initiation ART Eligible for ART HIV-positive Enroll in HIV care • Estimated that only 65% of eligible patients start treatment in RLS1 • Many lost to follow-up (LTF) or die prior to ART initiation2 • Retention and monitoring of patients not eligible for treatment at enrollment into care is challenging • Half of patients who are healthy at enrollment are lost before ART eligibility or initiation3 1Mugglin 2012; Rosen 2011; 2McGrath 2010, Geng 2012, Aliyu 2013; 3Krazner 2012

  4. Purpose of Study • Analysis of pre-ART outcomes for adult patients based on ART eligibility status at enrollment in HIV care in Ethiopia • Incidence of reaching ART eligibility for patients not eligible for treatment at enrollment • Incidence ART initiation for patients eligible at enrollment and those not eligible at enrollment but reached eligibility during follow-up • Factors associated with ART initiation • Routinely collected data from ICAP-supported care and treatment sites in Ethiopia • Identifying Optimal Models for HIV Care in Africa study • Data abstracted from patient charts, de-identified and entered into on-site electronic databases

  5. Methods (1) • All adults > 15 years enrolled in HIV care 2006 to 2011 • 45 health facilities, 4 Regions in Ethiopia • ART eligibility at enrollment assessed using CD4 and WHO stage data • 3 groups: eligible, ineligible, indeterminate (insufficient data) • Follow-up visit data used to identify date of ART eligibility & ART initiation *Ethiopian national ART guidelines changed August 2012

  6. Methods (2) • Cumulative incidence of reaching ART eligibility and ART initiation • Competing risk regression used to assess factors associated with ART initiation • Models adjusted for known predictors Eligibility to ART initiation Enrollment to ART eligibility Enroll in HIV care Initiate ART Eligible for ART Time from enrollment in care to ART eligibility among patients ineligible or indeterminate at enrollment Time from ART eligibility to ART initiation among patients eligible at enrollment or became eligible

  7. Selected adult patient characteristics (N=73,177)

  8. Enrollment to ART eligibility Cumulative incidence of reaching ART eligibility for patients ineligible or indeterminate at enrollment (N=35,376) • At 12 months after enrollment: • 23% of patients ineligible at enrollment reached ART eligibility • 35% of indeterminate patients reached ART eligibility Eligible for ART Enroll in HIV care Indeterminate Ineligible Competing risk estimators accounting for informative censoring

  9. Eligibility to ART initiation Cumulative incidence of ART initiation among adult patients by enrollment eligibility group (N=49,125) Initiate ART Eligible for ART • At 1 month from ART eligibility: • 66% of patients eligible at enrollment started ART • 47% of patients who were ineligible at enrollment & reached eligibility started ART • 66% of patients who were indeterminate at enrollment & reached eligibility started ART

  10. Eligibility to ART initiation Cumulative incidence of ART initiation among adult patients by enrollment eligibility group (N=49,125) Initiate ART Eligible for ART • At 3 months from ART eligibility: • 76% of patients eligible at enrollment started ART • 57% of patients who were ineligible at enrollment & reached eligibility started ART • 75% of patients who were indeterminate & reached eligibility started ART

  11. Eligibility to ART initiation Cumulative incidence of ART initiation among adult patients by enrollment eligibility group (N=49,125) Initiate ART Eligible for ART • At 6 months from ART eligibility : • 82% of patients eligible at enrollment started ART • 64% of patients who were ineligible at enrollment & reached eligibility started ART • 81% of patients who were indeterminate & reached eligibility started ART

  12. All patients Median CD4 count at enrollment and ART initiation by year (N=44,211) Enrollment CD4 233 Median CD4+ 141 147 112 ART initiation CD4 Median CD4 at enrollment increased from 141 cell/ml3 to 233 from 2006-2010 Median CD4 at ART initiation did not significantly increase

  13. Eligible at enrollment Median CD4 count at enrollment and ART initiation by eligibility group and year of ART initiation (N=44,211) Median CD4+ 106113 94 Enrollment CD4 141 ART initiation CD4

  14. Ineligible at enrollment Eligible at enrollment 427 Median CD4 count at enrollment and ART initiation by eligibility group and year of ART initiation (N=44,211) Enrollment CD4 323 232 212 ART initiation CD4 Median CD4+ 106113 94 Enrollment CD4 141 ART initiation CD4 Median CD4 at enrollment increased for ineligible patients 2006-2011 Patients still enrolling and starting ART with CD4 <200 (eligibility criteria unchanged)

  15. Factors associated with starting ART among all patient who reached eligibility • Multivariable competing risk regression models significant predictors of starting ART • Older age • 25-39 vs. 15-24yrs, aSHR*=1.2 (95% CI: 1.2-1.3) • 40-49 vs. 15-24yrs, aSHR=1.3 (95% CI: 1.2-1.4) • 50+ vs. 15-24yrs, aSHR=1.3 (95% CI: 1.2-1.3) • Lower CD4+ count • <100 vs. >350, aSHR=3.2 (95% CI: 2.8-3.5) • 100-199 vs. >350, aSHR=3.5 (95% CI: 3.2-3.9) • 200-350 vs. >350, aSHR=2.3 (95% CI 2.1-3.0) *aSHR: adjusted sub-distributional hazard model (using competing risk estimators)

  16. Strengths & Limitations • Strengths • Routine HIV care and treatment program data abstracted from patient charts • Representative, non-study settings • Large cohort of >73,000 patients • Limitations • Missing data • 40% missing CD4+ and 5% missing WHO stage at enrollment • Cannot identify reasons for individual patient management • Only analyzed those retained in care • Do not know outcomes for lost to follow-up prior to eligibility and ART initiation • LTF is differential based on eligibility status at enrollment

  17. Summary • Many patients eligible for ART at enrollment started treatment • 65% started ART within 1 month, 76% started within 3 months and 82% started within 6 months • Patients ineligible for ART at enrollment not rapidly initiated on ART after reaching eligibility • Only 64% started ART within 6 months after eligible • Many patients still enrolling and many initiating ART with advanced disease status • Median CD4 at enrollment and ART initiation in 2011: 233 and 147 cell/ml3, respectively

  18. Conclusions • Ethiopia has achieved success in scale up of HIV testing, care and treatment services • Greater efforts needed to ensure • Continued retention and monitoring of patients in care to identify when they become eligible • Rapid initiation of treatment once patients are ART eligible • Avoid late start of ART (CD4<200) • New ART eligibility guidelines (CD4 <350) will likely reduce ART initiation at advanced disease status

  19. THANK YOU Special thanks to all of the patients and staff at the health facilities and to the ICAP team in Ethiopia who supported the health facilities Thanks also to the Ethiopia Ministry of Health, CDC and PEPFAR for their support of ICAP and Optimal Models.

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