Extended ART Initiation Criteria Can Be Implemented Successfully in Rural South Africa Sarah Jane Steele1, Gemma Arellano2, Tom Ellman3, Amir Shroufi1, and Gilles van Cutsem1,3,4 1. Médecins Sans Frontières South Africa, Cape Town, South Africa; 2. Médecins Sans Frontières South Africa, Eshowe, South Africa; 3. Southern Africa Medical Unit (SAMU), Médecins Sans Frontières (MSF); 4. University of Cape Town, South Africa. THAB0101 Treat Early and Stay Suppressed July 21, 2016 11:00 – 12:30
No conflicts of interest to declare
Earlier ART initiation: The debate Background Earlier ART initiation: The debate For Against Improves health outcomes Decreases transmission “Sicker” patients will be “Crowded out” Implementation will be difficult
Project description “Bending the Curves” since April 2011 Reduce HIV incidence Reduce TB incidence Reduce HIV- and TB-related morbidity; and Reduce HIV- and TB-related mortality Extended ART initiation criteria from CD4 ≤ 350 to CD4 ≤ 500 in July 2014
Extended criteria + active outreach
Objectives To assess the impact of extending ART initiation criteria from CD4 ≤ 350 to CD4 ≤ 500 on: Percent initiated on ART by 3 months Retention in care at 12 months among people with different CD4 counts To discuss the feasibility and public health implications of extending ART initiation criteria
Methods Prospective cohort analysis Before (CD4 ≤ 350): July 1 – Dec 31, 2013 After (CD4 ≤ 500): July 1 – Dec 31, 2014 Exclusions: Pregnancy, TB, WHO stage 3 or 4, age <15 years Survival outcomes determined from last pre-ART CD4 Cumulative percent initiated on ART at 3 months Percent, on ART, RIC at 12 months
Baseline characteristics Before After N=1090 N=962 % Age Median (IQR) 30 (25-39) 29 (24-38) Sex Female 67.5 66.5 Baseline CD4 <200 21.6 20.5 201-350 27.9 27.7 351-500 22.1 22.7 >500 28.4 29.2
Cumulative percent initiated on ART at 3 months
Cumulative percent initiated on ART at 3 months
Cumulative percent initiated on ART at 3 months
Cumulative percent initiated on ART at 3 months
Cumulative percent initiated on ART at 3 months
Number of ART initiations
Lay counselor withdrawal WEPEC179 J. Hu et al. Lay counselor redeployment in KwaZulu-Natal, South Africa, leads to considerable drop in HIV testing
Percent RIC at 12 months
Percent RIC at 12 months
Percent RIC at 12 months
Percent RIC at 12 months
Percent RIC at 12 months
Public health implications
Population CD4 count among HIV-positive, not on ART Mbongolwane & Eshowe HIV Impact in Population Survey: Final Report: 2014, EpiCentre
Population CD4 count among HIV-positive, not on ART Mbongolwane & Eshowe HIV Impact in Population Survey: Final Report: 2014, EpiCentre
Population CD4 count among HIV-positive, not on ART Mbongolwane & Eshowe HIV Impact in Population Survey: Final Report: 2014, EpiCentre
Population CD4 count among HIV-positive, not on ART Mbongolwane & Eshowe HIV Impact in Population Survey: Final Report: 2014, EpiCentre
Who tests where? *Mobile and fixed site testing Operational PIMA results, 2014
Conclusions For newly eligible, extended criteria resulted in: Rapid but manageable increase in uptake of ART Retention in care >80% at 12 months No negative effects on patients with lower CD4 counts Test and start IS feasible with: Community, self- and other innovative testing models Lay workers Robust supply chain Differentiated models of care
Acknowledgements Thank you Clients and community members Lay workers DOH medical and administrative staff Thank you