1. Improving Patients Retention in Antiretroviral Treatment Programs: The experience of ARV Programs in Côte d’Ivoire Eugène MESSOU, MD, PhD CePReF- Aconda Attaché de recherches au Département de Dermatologie et d’infectiologie Université de Cocody, Abidjan, Côte d’Ivoire 1 Data published in : Messou, JAIDS 2011; 57:S34-S39

2. Background Successful scaling up: 3 million of patients treated in 6 years in sub-saharan Africa –Saving lives –Capacity bulding –Experience in how to implement large treatment programs 2

3. Standard of care, in Côte d’Ivoire * Antiretroviral treatment * Biologic / 6 months (CD4, hémog, urée, créat, glyc, transa) * Prophylaxis with Cotrimoxazole * Tuberculosis treatment * Other IO et Side effects Free 7.5 euros/6months No subvention

5. In January 2010 in Côte d’Ivoire * 404 sites ARV: publics (96%), privates (4%) * All the districts concerned * Cumulate number patients on ART: 117 584 * Still follow up on ART : 72 011 * Retention rate : 61.2%

6. Monitoring in the Aconda Program Toure S, AIDS 2008 Probability to be LTFU for the 10000 first adults patients

7. Background Many patients are Lost to Follow Up (LTFU) in routine care programs in sub-Saharan Africa Some factors associated with LTFU have been well identified However, interventions to decrease LTFU have been rarely assessed 7

8. Objectives 1.To assess whether simple enhancement of follow-up procedures decreases LTFU rates in a large HIV care clinic in Côte d’Ivoire 2.To examine factors associated with LTFU from month-6 to month-18 in this clinic and identify patients at month-6 for subsequent interventions to prevent further LTFU 8

9. Methods (1) Routine follow-up = CePReF, Abidjan –Current Active file : 8000 HIV-infected adults, including 3000 on ART –ART eligibility : WHO criteria –ART first line regimen: 2NRTI, plus NNRTI (HIV-1) or PI (HIV-2 or Dual, or history of pMTCT with NVP ) –CD4 and blood cell count every 6 month –3 social workers and 3 counselors, to take care of support group, telephone calls, home visits –Computerized system to record routine baseline and follow up data 9

10. Methods (2) Enhanced follow-up = « Voltart cohort » at CePReF –All patients who started ART at CePReF between June 2005 and May 2007, attended their 6-month visit, and signed informed consent –Follow-up procedures: same as for other patients followed up at CePReF, plus : Plasma HIV1 RNA test : free of charge, every 6 months 1 dedicated physician 1 dedicated monitor 10

11. Methods (3) For the present study : –Inclusion criteria : All adult who started ART between June 2005 and May 2008 at CePReF, and were alive and in care at Month-6 (M6) –Outcomes : death and LTFU at Month-18 (M18) –Analysis: Multivariate Cox regression, to estimate the association between the risk of being LTFU between M6 and M18 and baseline variables or type of follow-up (routine vs enhanced) Kaplan-Meier, to estimate the probability of being LTFU between M6 and M18, by type of follow-up and by medication possession ratio 11

12. Methods (4) Definition: –LTFU between M6 and M18 Last contact with the study team < M18 Not known to be dead or transferred out between M6 and M18, and no further information obtained up to M24 –Medication Possession Ratio (MPR) between M0 and M6 Number of daily doses of antiretroviral drugs dispensed by the pharmacy to each patient divided by the patient’s total follow-up time in days from ART initiation to M6 (or to last contact with care center if <M6) 12

13. Flow chart 13

14. Patient’s characteristics 14 MPR: Medication Possession Ratio M0: ART initiation; M6: 6 months after ART initiation

15. Factors associated with the risk of being LTFU between M6 and M18 15 MPR: Medication Possession Ratio AHR: adjusted Hazard Ratio

16. Probability of being LTFU between M6 and M18 16

17. Probability of being LTFU between M6- M18, by Medication Possession Ratio M0-M6 17 MPR: Medication Possession Ratio between M0 and M6

18. Discussion (1) 1.Simple enhancement of follow up starting at Month- 6 was independently associated with a 47% decrease in the risk of being LTFU between M6 and M18 –3 possible reasons: Mesuring viral load every six month... –Although we did not see a difference in mortality Being consistently attended by the same physician... One dedicated research assistant for 600 patients, to optimise rentention procedures –In a center where 6 social workers are already in charge of a current active file of 3000 patients 18

19. Discussion (2) 2.MPR during the first 6 month of ART in patients still alive and in care at month-6 was strongly associated with the risk of being LTFU between month-6 and month-18 –MPR could be used to identify those at highest risk of LTFU, in order to develop specifics interventions to improve their retention 19 Palombi, Clin Infect Dis 2009; 48 115-122 Bisson, PloS Med 2008;5:e109 McMahon, Clin infect Dis. 2011;52:493-506 Messou, JAIDS 2011; 57:S34-S39

21. Remerciements 21 CDC PEPFAR Programme Pacci site ANRS de Côte d’Ivoire Personnel du CePReF-ACONDA PNPEC Patients du CePReF et de toute l’Afrique subsaharienne SMIT du CHU de Treichville