Post on 24-Feb-2016
description
Matthew FoxCenter for Global Health & Development
Department of EpidemiologyBoston University
July 17, 2011
The first step is admitting you have a problem
Health Economics and Epidemiology Research Office
Wits Health Consortium University of the Witwatersrand
HERO2
• Defining the Problem• Stages of the Cascade• The Evidence for Retention by Stage– Pre-ART Care– ART Care
• Conclusions• The Way Forward
Overview of Presentation
How would an ideal HIV care and treatment program function?
Long term ARTMonitoring
Infe
ction
ART eligibleNot ART eligible
Disease Progression
Ideal Program Progression
Actual Program Progression
Long term ARTMonitoring
Testing & ReferralCompletion of referral
Staging
Determine ART eligibility
ART initiation
Testing & Referral
Completion of referral
Staging
Determine ART eligibility
ART initiation
Not staged
HIV+ population
ART eligible
Not yet ART eligible
Initiate ART
Tested
Not tested Staged
Retained through first
year
Lost before ART
initiationLost in first
year
Retained through ≈5
years
Lost by 5 years
Retained 5-30+ years
Lost after 5 yearsLost before ART
eligible
Pre-ART care until ART
eligible
Lifelong retention on treatment
Part I: Losses from testing to treatment initiation
From Testing to Treatment Initiation
CD4 results not obtained (not staged)
ART eligible
Not yet ART
eligible
Pre-treatment steps completed
CD4 results obtained (staged)
Lost before completing pre-treatment steps
Lost before enrolling in pre-
ART care
Enrolled in pre-ART care
CD4 count sample not
provided
CD4 count sample
provided
Lost before ART eligible
Pre-ART care until ART eligible
Initiate ART
Lost before ART initiation
HIV+ diagnosed population
Stage 1Testing to
staging
Stage 2Staging to ART
eligibility
Stage 3ART eligibility to
ART initiation
• Summary of evidence– 18% continuously in care if no “recycling”– 33% in most complete study (South Africa)2
– Are only 1/5 to 1/3 of those who test HIV+ retained in care continuously?
Source: Kranzer et al (2010)2
Stage 1 Stage 2 Stage 3 Medians Multiplied
0%20%40%60%80%
100%
59%46%
68%
18%
Median % Completing Stage (Range)
Rosen & Fox, PLoS Medicine 2011, in press
It’s not just retention, but active engagement, timely completion of stages that is necessary
Ingle et al. AIDS 2010
Not staged
HIV+ population
ART eligible
Not yet ART eligible
Initiate ART
Tested
Not tested
Staged
Retained through
first year
Lost before ART
initiationLost in first
year
Retained through ≈5
yearsLost by 5
yearsRetained
5-30+ years
Lost after 5 yearsLost before
ART eligible
Pre-ART care until ART
eligible
Part II: Lifelong retention on treatment
Losses On ART: 2007 vs. 2010
2010Fox and Rosen, TMIH 2010
2007Rosen, Fox and Gill PLoS Medicine 2007
60% Retention at 24 months
70% Retention at 24 months
What Happens to Patients Lost from ART Care?
Brinkhof et al., PLoS One 2009
Unstructured Treatment Interruptions
• Treatment interruptions common– To manage toxicity, treatment fatigue, etc.
• Median % interrupting treatment was 23.1% – IQR: 14%-48%– Include developing and developed country data
• Variable definitions of duration of treatment interruptions– Often undefined
Kranzer and Ford, TMIH 2011, in press
The Way Forward• Better Measures of pre-ART Losses– Standard Definitions– Populations: Pregnant women, children
• Investigate Reasons for Losses• Track Progress on Losses Over Time– Focus on pre-ART and Long Term ART
• Develop/Target Intervention to Reduce Losses– Reducing visit time/number of visits, travel vouchers, relocate
services, combine ANC/ART, same day ART initiation, reminders, provide pre-ART services (cotrimox, INH), incentives, etc.
• U.S. Agency for International Development/South Africa (Melinda Wilson)
• National Institute of Allergy and Infectious Diseases, U.S. National Institutes of Health
• Boston University Center for Global Health & Development, Boston, USA
• Health Economics and Epidemiology Research Office (HE2RO), Wits Health Consortium, University of the Witwatersrand, Johannesburg, South Africa
Acknowledgements
Health Economics and Epidemiology Research Office
Wits Health Consortium University of the Witwatersrand
HERO2