1. 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

2. No conflicts of interest to declare

3. 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

4. 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

5. Extended criteria + active outreach

6. 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

7. 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

8. 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
27.9
27.7
22.1
22.7
>500
28.4
29.2

9. Cumulative percent initiated on ART at 3 months

10. Cumulative percent initiated on ART at 3 months

11. Cumulative percent initiated on ART at 3 months

12. Cumulative percent initiated on ART at 3 months

13. Cumulative percent initiated on ART at 3 months

14. Number of ART initiations

15. Lay counselor withdrawal
WEPEC179
J. Hu et al. Lay counselor redeployment in KwaZulu-Natal, South Africa, leads to considerable drop in HIV testing

16. Percent RIC at 12 months

17. Percent RIC at 12 months

18. Percent RIC at 12 months

19. Percent RIC at 12 months

20. Percent RIC at 12 months

21. Public health implications

22. Population CD4 count among HIV-positive, not on ART
Mbongolwane & Eshowe HIV Impact in Population Survey: Final Report: 2014, EpiCentre

23. Population CD4 count among HIV-positive, not on ART
Mbongolwane & Eshowe HIV Impact in Population Survey: Final Report: 2014, EpiCentre

24. Population CD4 count among HIV-positive, not on ART
Mbongolwane & Eshowe HIV Impact in Population Survey: Final Report: 2014, EpiCentre

25. Population CD4 count among HIV-positive, not on ART
Mbongolwane & Eshowe HIV Impact in Population Survey: Final Report: 2014, EpiCentre

26. Who tests where? *Mobile and fixed site testing
Operational PIMA results, 2014

27. 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

28. Acknowledgements Thank you
Clients and community members Lay workers DOH medical and administrative staff
Thank you