Matthew Fox Center for Global Health & Development Department of Epidemiology Boston University July 17, 2011 The first step is admitting you have a problem.

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