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Poor linkage to care despite significant improvement in access to early cART – data from Test and Keep in Care (TAK) project. Leah Shepherd, Magdalena.

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Presentation on theme: "Poor linkage to care despite significant improvement in access to early cART – data from Test and Keep in Care (TAK) project. Leah Shepherd, Magdalena."— Presentation transcript:

1 Poor linkage to care despite significant improvement in access to early cART – data from Test and Keep in Care (TAK) project. Leah Shepherd, Magdalena Ankiersztejn-Bartczak, Aneta Cybula, Hanna Czeszko-Paprocka, Ewa Firląg-Burkacka, Andrzej Horban, Amanda Mocroft and Justyna D. Kowalska Test and Keep in Care Hospital for Infectious Diseases, HIV Out-Patients Clinic, Warsaw, Poland, Medical University of Warsaw, Department for Adults' Infectious Diseases, Warsaw, Poland

2 So… where we are? Unemployment Avarage salary Migration (saldo)

3 Background - Europe  Up to 50% of HIV-infected remain undiagnosed  Half of newly diagnosed are late presenters  Increased HIV testing and improving care pathway are strongly encouraged  Only persons linked to care can fully benefit from being diagnosed  It is unknown how many diagnosed patients remain outside care Antinori A. Antivir Ther 2010, Mocroft A. PLoS 2013, Wynberg E JIAS 2014

4 Test and Keep in Care (TAK) project  Prospective follow-up of HIV persons diagnosed in CBVTC in central Poland  Data collection: pre-clinical from CBVTC questionnaire (standardized by National AIDS Centre) clinical from HIV clinics  Main end-point: linkage to care  Study aims: estimate the prevalence of HIV(+) lost or late to care investigate related factors and target effective interventions Ankiersztejn-Bartczak M. HIV Med. 2015

5 Methods  data from CBVTC (2010-2013/14) and HIV clinics were linked using unique Western-Blot number  linked to care = tested at CBVTC and registered in HIV clinics  latest follow up date was 4/06/2014

6 Counselling ELISA + result not collected by CBVTC client Lost to care WB+ result not collected by CBVTC client Lost to care Decoding not agreeLost to care Clinic not regisdteredLost to care Linked to care From CBVTC to HIV clinic HIV clinic Anonymoust testing at CBVTC

7 Methods - Statistical analyses  Cox-proportional hazard models were used to identify factors associated with: being linked to care (LTC) – baseline date of HIV test starting cART – baseline date of first visit to HIV clinic  Both pre-clinical (16) and clinical factors (5) were included into analyses and tested as potential predictors of linkage to care

8 Results – linked to care  232 persons tested HIV+ in CBVTC  144 (62.1%) were linked to care (95%CI:60%-70%)  81.2% registered within 3 months from testing  Medial follow-up per person 3 months (95%CI:1-23)  239 person years of follow-up

9 Baseline characteristics for those who were tested Median (IQR) Total n (%)Not linked to careLinked to careP value Total number232 ( 100)88 ( 100)144 ( 100)- Age at test <=30*116 (50.0)50 (56.8)66 (45.8)0.105 Male sex220 (94.8)83 (94.3)137 (95.1)0.784 Polish nationality223 (96.1)83 (94.3)140 (97.2)0.276 High education180 (77.6)63 (71.6)117 (81.3)0.089 MSM175 (75.4)55 (62.5)120 (83.3)<.001 Test at CBVCT128 (55.2)44 (50.0)84 (58.3)0.216 No test last year65 (28.0)25 (28.4)40 (27.8)0.917 Year of test 201032 (13.8)14 (15.9)18 (12.5)0.575 201176 (32.8)31 (35.2)45 (31.3) 201270 (30.2)22 (25.0)48 (33.3) 201354 (23.3)21 (23.9)33 (22.9) * median age 30.1 (IQR: 25.2-35.9) years

10 Baseline characteristics for those who were tested Median (IQR)Total n (%)Not linked to careLinked to careP value STI35 (15.1)11 (12.5)24 (16.7)0.391 Partner tested84 (36.2)32 (36.4)52 (36.1)0.969 Partner HIV+53 (22.8)13 (14.8)40 (27.8)0.024 Stable relationship within last year 27 (11.6)15 (17.0)12 ( 8.3) 0.049 Condom use with stable partners 100 (43.1)30 (34.1)70 (48.6)0.031 Condom use with casual partners 132 (56.9)47 (53.4)85 (59.0)0.402 No of stable partners 1-5, unknown67 (28.9)29 (33.0)38 (26.4)0.549 6-2093 (40.1)34 (38.6)59 (41.0) >2172 (31.0)25 (28.4)47 (32.6) No of casual partners 1-5, unknown176 (75.9)69 (78.4)107 (74.3)0.495 6-2040 (17.2)12 (13.6)28 (19.4) >2116 ( 6.9)7 ( 8.0)9 ( 6.3)

11 Kaplan-Meier plots

12 Linked to care Unadjusted hazard ratios and 95% CI * or unknown Only variables significant in univariate analyses (p <0.1) are shown above better linkage worse linkage

13 Linked to care Unadjusted and adjusted hazard ratios and 95% CI Multivariate models adjusted for variables significant in univariate analyses (p <0.1) as shown above * or unknown better linkage worse linkage

14 Results – starting cART  116 (80.5%) started cART during follow up  CD4 count was 393 (292-506) cells/ul *  HIV RNA was 4.5 (3.9-5.1) log copies/ml*  Median follow-up per person 3 (95% CI:1-16) months  118 person years of follow-up  Pre-clinical characteristics were similar for patients who started and not started cART * Median (IQR) of baseline measurement at first clinic visit

15 Clinical characteristics for those who were linked and started cART Median (IQR)Total n(%) Not started cART Started cARTP value anti-HBc at first visit Yes16 (11.1)5 (18.5)11 ( 9.4)0.40 No103 (71.5)18 (66.7)85 (72.6) Unknown/missing25 (17.4)4 (14.8)21 (17.9) anti- HCV at first visit Yes3 ( 2.1)0 ( 0.0)3 ( 2.6)0.78 No125 (86.8)25 (92.6)100 (85.5) Unknown/missing16 (11.1)2 ( 7.4)14 (12.0) Syphilis at first visit Yes30 (20.8)7 (25.9)23 (19.7)0.47 No/undetermined100 (69.4)19 (70.4)81 (69.2) Unknown/missing14 ( 9.7)1 ( 3.7)13 (11.1) HIV RNA at baseline 0 - 10,00040 (27.8)16 (59.3)24 (20.5)<.001 <10,000104 (72.2)11 (40.7)93 (79.5) CD4 at baseline 1 - 35049 (34.0)2 ( 7.4)47 (40.2)0.005 351 - 50058 (40.3)12 (44.4)46 (39.3) > 50037 (25.7)13 (48.1)24 (20.5)

16 Kaplan-Meier plots

17 50% 60% 90%

18 Started cART Unadjusted hazard ratios and 95% CI * or unknown Only variables significant in univariate analyses (p <0.1) are shown starting cART delaying cART

19 Started cART Unadjusted and adjusted hazard ratios and 95% CI * or unknown starting cART delaying cART

20 Limitations  patients classified as lost to care could migrated to or registered at non-regional clinics rather trend towards centralisation of migration for care  it is not possible to perform external quality assurance to exclude double testing in Polish settings (anonymous registration) patients re-test mostly due to undetermined WB result

21 Conclusions  Benefits of HIV care, measured by access to early treatment, steadily improved in recent 4 years  1 in 3 persons aware of their HIV status remain outside professional healthcare  Bi/heterosexual persons with primary/unknown education are at higher risk of remaining outside care despite being diagnosed

22 Perspectives  All CBVTC in Poland record Western blot test numbers as a possible cross-check  To develope coding system allowing for outcome measures of care pathway  Next TAK step is introducing targeted intervention in 2015

23 Acknowledgments  unrestricted research grant received from :  data from testing facilities were provided by National AIDS Centre (Krajowe Centrum AIDS) and Foundation of Social Education

24 To all people who continuously support us.Thank you

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