Task-shifting of HIV care and ART initiation: Three year evaluation of a mixed-care provider model for ART delivery Megan McGuire 1, Jihane Ben-Farhat 1, Gaelle Pedrono 2, Sylvie Goossens 3, Annette Heinzelmann 3, Owen Chikwaza 4, Elisabeth Szumilin 3, Mathilde Berthelot 3, Mar Pujades-Rodriguez 5 1 Epicentre, Nairobi, Kenya, 2 Médecins Sans Frontières, Chiradzulu, Malawi, 3 Médecins Sans Frontières, Paris, France, 4 Ministry of Health, Chiradzulu, Malawi, 5 Epicentre, Paris, France

Background and Objective Physician centered ART delivery models are not replicable in settings with high HIV prevalence and limited medical human resources –Utilizing mixed level cadres of staff could facilitate scaling up of care 2010 monthly program activity: 14,000 HIV consultations, 700 program enrollments and 400 ART initiations We compared treatment outcomes of patients receiving ART and followed by different types of providers in a large HIV program in rural Malawi

Methods Eligibility criteria for nurse care: ART naïve at therapy start, in WHO stage 1 or 2, CD4 count >100 cells/μL, BMI >17 kg, on first line. Study population: Inclusion of 10,112 adults (>15 years) who started ART between Sept March Study definitions: ≥80% of visits by either nurse or clinical officer, <80% of visits in mixed group. Statistical analysis: Follow-up was right-censored at the earliest of the following dates: death, transfer out, last visit or 24 months of follow-up. –Multivariable Poisson models to compare 2-year mortality and program attrition by type of provider –Sensitivity analysis: patients with BMI>18.5 kg/m 2, clinical stage 1 or 2 and CD4>100

Characteristics at ART start Characteristics Nurses N=1901 COs N=3386 Mixed group N=4825 Total N=10112 Women (%)1 263 (66.4)1 905 (56.3)3 276 (67.9)6 444 (63.7) Median age, years [IQR]35 [29 – 43]35 [30– 43]34.9 [29– 43]35.1 [29 – 43] BMI, kg/m² (%) < (15.4)1 197 (35.4)1 250 (25.9)2 740 (27.1) Clinical stage (%) Stage 1 or 2 Stage 3 or (74.4) 363 (19.1) (34.5) (58.9) 2773 (57.5) (33.1) (52.9) (39.2) Median CD4 count, [IQR] cells/μL 195 [147 – 234]147 [69 – 228]182 [113 – 233]178 [105 – 232]

Mortality and Attrition

All patients aIRR (95% CI) Less severe patients* aIRR (95% CI) Mortality Nurse11 Mixed0.72 ( )0.84 ( ) Clinical Officer5.04 ( )5.80 ( ) Attrition Nurse11 Mixed0.54 ( )0.63 ( ) Clinical Officer4.71 ( )3.42 ( ) * BMI>18.5 and WHO stage 1 or 2 and CD4>100, N=3846 NurseClinical OfficerMixed Group At 12 months207 [118 – 317]168 [81 – 278]195 [112 – 301] At 24 months253 [164 – 377]244 [150 – 387]270 [166.5 – 403.5] CD4 count gains since ART start by type of provider, cells/μL Association between mortality or attrition by type of provider

Discussion Mortality was similar in the nurse and mixed care groups during the first 2 years of ART, but program retention was lower in the first group These results support the use of a mixed care approach with well trained and supervised nurses for the provision of HIV care –Use of clear clinical criteria for inclusion and referral of patients is essential –National policies need to be adapted to ensure continuation of ART scale-up, including ART initiation and follow-up, nurse deployment for HIV care as complementary workers is essential. Limitations: Observational study based on routine monitoring data; severe or complicated patients primarily treated by or referred to CO’s. Nurses have additional responsibilities in HC. A competing risk analysis needs is to be done as a further sensitivity analysis. See poster presentation MOPE436 on six month appointments