Changing Characteristics of HIV-infected Patients Initiating ART in East Africa 1998-2008
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Changing Characteristics of HIV-infected Patients
Initiating ART in East Africa1998-2008
PW Hunt, K Wools-Kaloustian, S Kimaiyo, L Diero, WM Tierney, BS Musick, P Braitstein, P Easterbrook, C
Cohen, GR Somi, MB Bwana, E Geng, DR Bangsberg, JN Martin, and CT Yiannoutsos
For the East Africa IeDEA Consortium
East Africa
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Background• ART programs have rapidly scaled up throughout East
Africa in the past 5 years
– Greatest pharmacologic intervention ever
• Roll-out has been dynamic, and change has been the rule
• Characteristics of ART initiators are likely to have changed in important ways in this rapid scale-up
• Understanding these changes may help in:
– Evaluating penetrance of the roll-out
– Interpreting effects of roll-out (treatment outcomes)
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Objective• Among ART initiators in East Africa,
evaluate temporal trends in:
– Method of payment (self-pay vs free)– Distribution of age and gender– Proximity of residence to clinic– Stage of disease at initiation– Speed with which ART is initiated
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East Africa
Adult and Pediatric Sites
Mbale
Masaka Mbarara
Ocean Road Cancer Institute
Morogoro Tumbi
AMPATH
FACES Nyanza Provincial Hospital
•IDI•St. Francis•Mulago
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Patients
• Selected all adults (>18) initiating their first combination antiretroviral therapy (ART) regimen
• Women with prior ART use for PMTCT included
Analysis
• Stratified by year of ART initiation
• Assessed temporal trends in characteristics
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# Clinics Contributing ART Initiators to Analysis Since 1998
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57,415 Patients Initiated ART Since 1998Dramatic Increase after 2003 PEPFAR Roll-Out
PEPFAR
Global Fund
MAP
7 11 30 143
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Year of ART Initiation
# P
atie
nts
In
itia
tin
g H
AA
RT
PEPFAR
Global Fund
MAP
Kenya
Uganda
Tanzania*
*
* 2008 data incomplete
ART supply interrupted 2ary MOH fraud
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“Self Pay” Era Ended in 2004
PEPFAR
Global Fund
MAP
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End of Self Pay Coincides With Dramatic Expansion of ART Access
PEPFAR
Global Fund
MAP
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Changing Demographics of ART Initiators Over Time
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Age of ART Initiators IsGradually Decreasing Over Time
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Women Account For an Increasing Proportion of ART Initiators Over Time
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Increase in % Women Was More Notable in Uganda Than in Kenya and Tanzania
Uganda Kenya/Tanzania
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Has the % patients initiating ART at advanced disease stages been
changing over time?
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Decreasing % Patients Initiating ART with Stage IV Disease
PEPFARGlobal Fund
MAP
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Decrease in WHO Stages III/IV at ART Initiation Over Time
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Nearly 60% of men initiated ART at WHO Stage III or IV
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Women Much Less Likely To Initiate ART at Advanced Disease Stages
Consistent Trend Across All Years
PMTCT programs may allow for
diagnosis of women at earlier disease
stages.
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Women With Prior Hx PMTCT Initiated Therapy at Less Advanced Disease Stage
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CD4 Counts at ART Initiation Increasing in the PEPFAR Era
PEPFARGlobal Fund
MAP
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What about opportunistic diseases among ART initiators?
Have these changed over time?
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Despite initial decline, active TB remains very common among ART initiators
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Has the proliferation of HIV clinics providing ART in East Africa led to measurable decreases in the
barriers to access ART?
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Average Travel Time to Clinic Has Declined(Data currently only available for Kenya)
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Have increasing numbers of patients starting ART strained clinic
capacity, introducing delays to initiate therapy?
Among patients who started ART, what was the average delay from WHO III/IV
diagnosis to ART initiation?
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Apparent increasing delay to ART in patients with WHO Stage III Disease, but still ≤ 1 month
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No apparent increase in delay to ART for Patients with WHO Stage IV Disease
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ConclusionsThe Early Successes
• As ART programs have rolled out in East Africa:
– Dramatically more patients are accessing free therapy
– Access to clinics is improving (decreased travel time)
– More women are accessing ART
– Patients initiating therapy at less advanced disease stage
• These observations document a major early impact of the ART roll-out in East Africa.
• All of these factors should improve treatment outcomes over time.
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Conclusions (II)Continuing Challenges
• While patients are initiating therapy at earlier disease stages, most patients continue to start therapy late (CD4<200).
– Need to re-double efforts to diagnose and get patients into care earlier.
• While TB prevalence among ART initiators may have decreased initially, it remains VERY common (~20%).
• While access to ART is improving, 1 out of every 6 patients is still traveling >2 hours to reach clinic.
– Desperately need to improve access for patients in rural areas
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AcknowledgementsAMPATHLameck Diero
Sylvester Kimaiyo
Samwel Ayaya
Winstone Nyandiko
Edwin Sang
Indiana University
Kara Wools-Kaloustian
Paula Braitstein
Bill Tierney
Beverly Musick
Constantin Yiannoutsos
FACESElizabeth Bukusi
Frankline Onchiri
Patrick Oyaro
UCSF
Cinthia Blatt
Starley Shade
Jayne Kulzer
Craig Cohen
East Africa
Mbarara / MUSTMwebesa Bwana
Nicholas Musinguzi
Winnie Muyindike
UCSF
Elvin Geng
John Bennett
Megan Lazzar
Jeff Martin
Harvard University / MGH
Nneka Emenyonu
David Bangsberg
IDI - KampalaPhilippa Easterbrook
Richard Orama
Agnes Kiragga
Andrew Kambugu
Damalie Nakanjako
Moses Kamya
MasakaJohn Ssali
NACPG.R. Somi
Roland Swai
Tumbi Isaria Maruchu
MorogoroRita Lyamuya
ORCIHussein Mtiro