Using HIV cohort collaboration data to evaluate and inform policy and practice Mary-Ann Davies

Overview What is IeDEA-Southern Africa? Using IeDEA-SA data to evaluate and inform policy Lessons learned

Overview What is IeDEA-Southern Africa? Using IeDEA-SA data to evaluate and inform policy Lessons learned

What is IeDEA-Southern Africa? International epidemiologic databases to evaluate AIDS NIH-funded regional collaboration of HIV cohorts that identifies and pursues research relevant to the region that can’t be addressed in a single cohort Data centres University of Bern, Switzerland; University of Cape Town, South Africa Together with 6 other regions – contribute to the global IeDEA collaboration (www.iedea.org) This is a slide to introduce the collaboration

15 Cohorts in 6 Countries >900,000 adults >60,000 children Purple shading includes children, Red boxes – children only  >900,000 adults >60,000 children

Overview What is IeDEA-Southern Africa? Using IeDEA-SA data to evaluate and inform policy Adults: Life expectancy on ART (South Africa) Maternal health: Implementation of Option B+ (Malawi) Children: When to start ART (with IeDEA-WA & Europe) Lessons learned

Overview What is IeDEA-Southern Africa? Using IeDEA-SA data to evaluate and inform policy Adults: Life expectancy on ART (South Africa) Maternal health: Implementation of Option B+ (Malawi) Children: When to start ART (with IeDEA-WA & Europe) Lessons learned

Life expectancies of adults starting ART in South Africa (using linkage to SA vital registry) Near-normal life expectancy for adults starting ART with CD4 >200 Johnson et al, PLoS Med 2013

Why does life expectancy matter? Evaluating ART program effectiveness Forecasting future program costs Advocacy – life insurance

Overview What is IeDEA-Southern Africa? Using IeDEA-SA data to evaluate and inform policy Adults: Life expectancy on ART (South Africa) Maternal health: Implementation of Option B+ (Malawi) Children: When to start ART (with IeDEA-WA & Europe) Lessons learned

3- year outcomes of Option B+ in Malawi Pregnant Breastfeeding Own health Died Stopped ART Lost to follow-up No follow-up Tenthani et al. AIDS 2013 Haas et al. Lancet HIV 2016

Outcomes of Option B+ in Malawi Reason for start No follow-up (aHR) Year 1 LTFU (aHR) Year 2 LTFU (aHR) Year 3 LTFU (aHR) Own health 1 Option B+ pregnancy 4.7 (4.3-5.2) 1.6 (1.5-1.8) 1.4 (1.2-1.5) 1.2 (0.9-1.4) Option B+ breastfeeding 2.5 (2.1-2.9) 1.05 (0.9-1.2) 1.2 (1.0-1.4) 0.9 (0.7-1.2) p-value <0.0001 0.2 Tenthani et al. AIDS 2013 Haas et al. Lancet HIV 2016

Option B vs Option B+ Minimal drop off in retention in years 2 & 3 Patients likely to be on ART at start of next pregnancy Compared to Option B, Option B+ averts 1 additional infection per 200 women mostly because patients on ART at start of subsequent pregnancy Tweya et al. AIDS 2016

Overview What is IeDEA-Southern Africa? Using IeDEA-SA data to evaluate and inform policy Adults: Life expectancy on ART (South Africa) Maternal health: Implementation of Option B+ (Malawi) Children: When to start ART (with IeDEA-WA & Europe) Lessons learned

Should we start ART earlier in older children? 2010 2013

Evidence for children and adolescents? Fewer severe disease events with immediate vs deferred ART in adults with high CD4 counts

Using causal modelling to adjust for time-dependent confounding To use observational data from children aged 5-16 years in the IeDEA-West Africa, IeDEA-Southern Africa and COHERE (Europe) collaborations to compare Cumulative mortality Growth for different ART initiation strategies starting ART immediately, irrespective of CD4 criteria ≈WHO 2015 starting ART when CD4 drops below 500 or WHO Stage 3 or 4 ≈WHO 2013 Using causal modelling to adjust for time-dependent confounding Schomaker et al. IJE In press.

Mortality – age 5-10 – CD4> 500 No ART 0.4% (0.02%;0.6%) Immediate ART

Overview What is IeDEA-Southern Africa? Using IeDEA-SA data to evaluate and inform policy Lessons learned

Lessons learned Working with policy makers & site investigators Value of collaboration Enhancing cohort data Statistical methodological work Incorporating additional data Overcoming shortcomings of observational data

With many thanks to… Patients, caregivers, staff and site investigators from all IeDEA-SA sites Everyone at IeDEA Data Centres in Bern and Cape Town NIAID, NICHD, NCI, NIMH, NIDA