1. Early Access to ART for All (EAAA) Swaziland Implementation “Treat All” Pilot 2014-2017

2. First roll out of universal access to antiretroviral therapy under routine program conditions in rural Swaziland.
Authors: Bernhard Kerschberger (1), Sikhathele Mazibuko (2), Inoussa Zabsonre (1), May Myat Win (1), Roger Teck (3,4), Serge Kabore (1), Mpumelelo Ndlangamandla (1), David Etoori (1), Iza Ciglenecki (4)
Affiliation:
(1) Medecins sans Frontieres (OCG), Mbabane, Swaziland
(2) SNAP, Ministry of Health, Mbabane, Swaziland
(3) Medecins Sans Frontieres, Southern Africa Medical Unit (SAMU), Cape Town, South Africa
(4) Medecins sans Frontieres (OCG), Geneva, Switzerland
Contact: Bernhard Kerschberger

3. Context- Swaziland Population: 1,2 million
HIV prevalence: 31% (SHIMS 2011)
HIV incidence: 2.38% (adults, SHIMS 2011)
Since 2008, HIV/TB services scaled-up & decentralized
ART coverage >90% (CD4 350; 2014)

4. Two “Treat All” pilots in Swaziland, since 2014
MoH/ MaxART project in northern Swaziland (Hhohho)
MoH/MSF project in southern Swaziland (Shiselweni)

5. “Treat All” pilot in Shiselweni (MoH/MSF)
To determine whether “Treat All” is
Feasible under routine program conditions
Acceptable for patients with high CD4 levels ( / ≥500)
To compile Lessons learned and Recommendations on the best way this approach can be implemented in Swaziland and similar settings

6. Design: Prospective two arm cohort study to describe ART initiation and patient outcomes under the “Treat All” approach
Eligibility: all HIV+ pre-ART patients ≥ 16 years of age (excluding women under PMTCTB+)
Location: 1 rural health zone (1 secondary facility, 8 nurse-led primary care facilities)

7. Analysis: Baseline & Time to ART initiation
Descriptive statistics
Kaplan Meier estimates:
Time from pre-ART registration to ART initiation for newly diagnosed HIV+ patients (20 Oct May 2015)
Retention on ART for newly HIV+ AND known pre-ART patients (20 Oct Mar 2015 & follow-up until 15 Aug 2015)
VL utilization & outcomes

8. Baseline characteristics at pre-ART registration
431 pre-ART registrations (new HIV+)
Median CD (83-446)
Men- 36%
Median age- 32 (25-40)
55% of all pre-ART registrations at primary care facilities

9. Time to ATR initiation Overall, 85% ART initiation at 3 months.
Same probability of ART initiation across CD4 strata (p=0.37).
P=0.37
32% same-day treatment initiation
CD4 at pre-ART registration
3 months ART initiation
0-359
89%
≥500
80%

10. Early retention in ART care
Tendency of higher ART retention for patients in higher CD4 strata (p=0.06)
P=0.06
Between 3-6% of patients default within first 2 weeks after ART initiation
RETENTION
0-349
≥500
2 weeks
97%
94%
96%
3 months
85%
89%
92%
6 months
81%
86%
87%

11. Viral load utilization (at 3-9 months since ART)
Low VL utilization at 6 months (30%).
At 9 month 67%
No difference in VL utilization across CD4 strata.
P=0.38
VL utilization
0-349
≥500
6 months
26%
31%
36%
9 months
65%
70%
67%

12. High viral load suppression rate (<1,000)
90%
97%
95%
Overall, 94% VL suppression
VL suppression comparable across CD4 strata (p=0.15)

13. Challenges

14. Health workers feedback:
Fears before “Treat All” pilot-
Perceptions after implementation start
Work load will increase too much
“Treat All” is a good idea, it was good to start…”
Generally patients accept “Treat All”
Do we have enough ARVs?
Work load is manageable at primary care clinics
Patients with high CD4 will not accept ART and will not stay on treatment
Enough ARVs available.

15. Support activities for “Treat All”
No additional resources at primary care clinics
Separated OPD - ART services at secondary facility as barriers for in-facility linkage to HIV care
One additional nurse at OPD to facilitate linkage to HIV care
Community ART delivery models introduced (to alleviate patient burden at health facility, and enable patient peer-support)

16. Conclusions Implementation challenges were less than expected
>50% of ART initiations/ follow-up at nurse-led primary care clinics
First early treatment outcomes and VL suppression rates encouraging, and similar across CD4 strata (Preliminary analysis)
The early findings of this implementation pilot are positive. This suggests feasibility/ acceptability of “Treat All” approach in the context of Swaziland.

17. Thank you Acknowledgements-
Patients and the Community of Nhlangano Health Zone
Health workers, Regional Health Management Team
SNAP (Swaziland National Aids Program)
MSF
CHAI