CROI 2015 Program and Abstracts

Abstract Listing

Oral Abstracts

154 Disparities in Engagement Within HIV Care in South Africa Simbarashe Takuva 1 ; Alison Brown 2 ;WilliamMacleod 3 ;Yogan Pillay 4 ;Valerie Delpech 2 ; Adrian J. Puren 1 1 National Institute for Communicable Diseases, NHLS, Johannesburg, South Africa; 2 Centre for Infectious Diseases Surveillance, Public Health England, London, United Kingdom; 3 Boston University, Boston, MA, US; 4 National Department of Health, Pretoria, South Africa Background: South Africa (SA) has the largest population of persons living with HIV/AIDS (PLHIVA) in the world. While antiretroviral therapy (ART) provision has rapidly expanded with >2,000,000 people on ART by end of 2012, there were an estimated 400,000 number of new HIV infections in 2012. We characterise engagement within HIV care in 2012 to monitor the effectiveness of the HIV programme and identify areas for improvement. Methods: National Health Laboratory Service electronic data, a repository for all public sector laboratory measurements in SA were used. Over 3,900,000 CD4 count and viral load measurements conducted in 2012 were extracted, matched then de-duplicated using probabilistic record linkage. The number of PLHIVA was estimated using HIV prevalence estimates from the national household survey. We calculated number and proportion of persons in HIV care, on ART and with viral suppression (viral load<400 copies/ml). We further stratified analysis by gender and age-group. Multivariate regression models were to examine viral suppression rates among those on ART. Results: Among 6,422,000 PLHIVA in SA in 2012, an estimated 3,300,000 persons (51.4%) accessed care and 34%were on ART. While viral suppression rate was 73.5% among the treated population, the overall percentage of persons with viral suppression among the HIV-infected population was 25.0%, corresponding to potentially 4,500,000 infectious persons. Engagement in care among males was poorer across all stages with only 18.8%with viral suppression (see figure). In the 0-14 age-group, majority in care were on ART (167,000/171,000). Notably, among the sexually active 15-49 year age-group, 47.8%were linked to care, 31.7%were on ART and only 21.5% had viral suppression. Among individuals on ART, males (aPR=0.93, 95%CI 0.93-0.93) and younger persons (aPR=0.94, 95%CI 0.94-0.94; aPR=0.76, 95%CI 0.76-0.76 and aPR=0.77, 95%CI 0.76-0.77 for age- groups 25-49, 15-24 and 0-14 years vs. age 50+ years respectively) were less likely to achieve viral suppression.

Conclusions: Although the number receiving ART has massively increased in SA, an estimated three-quarters of PLWHA have not achieved viral suppression. Expanding HIV testing, strengthening and maintaining prompt linkage to care is crucial. Males and the sexually active 15-49 year age-group have poorer engagement in all stages of care. These groups should be the main focus of prevention efforts as they are potentially driving transmission of new HIV infections in the general population. 155 Decentralizing Access to Antiretroviral Therapy Services for Adults in Swaziland Andrew F. Auld 1 ; Harrison Kamiru 2 ; Charles Azih 3 ; Andrew L. Baughman 1 ; Harriet Nuwagaba-Biribonwoha 2 ; Peter Ehrenkranz 1 ; Simon Agolory 1 ;TeddV. Ellerbrock 1 ;Velephi Okello 3 ; George Bicego 1 1 US Centers for Disease Control and Prevention, Atlanta, GA, US; 2 ICAP, Columbia University, New York, NY, US; 3 Ministry of Health, Mbabane, Swaziland Background: In 2007, Swaziland initiated a hub-and-spoke model for decentralizing antiretroviral therapy (ART) access. Decentralization was facilitated through: (1) down- referral of stable ART patients from overburdened central facilities (hubs) to primary healthcare clinics (spokes), and (2) ART initiation at spokes (spoke-initiation). To inform decentralization efforts, a nationally representative retrospective cohort study among adults ( ≥ 15 years old) starting ART during 2004–2010, was implemented to assess the effects of down-referral and spoke-initiation on rates of loss to follow-up (LTFU), death, and attrition (death or LTFU). Methods: Sixteen of 31 ART hubs were randomly selected using probability-proportional-to-size sampling. Seven selected facilities had initiated the hub-and-spoke model by study start. At these facilities, 1,149 of 24,782 hub-initiated and maintained, and 878 of 7,722 down-referred or spoke-initiated patient records were randomly selected. At the nine hub-only facilities, 483 of 6,638 records were randomly selected. Characteristics at ART initiation were compared between hub-only (n=483), hub-initiated and maintained (n=1,149), hub-initiated but down-referred (n=367), and spoke-initiated (n=511) adults. Multivariable proportional hazards regression was used to assess effect of down-referral (a time-varying covariate) and spoke-initiation on outcomes. Results: At ART initiation, median age was 35, 65%were female, and median CD4 count was 147 cells/ m L, with no significant differences in these variables between groups. However, down-referred or spoke-initiated patients tended to have higher median weight, higher functional status, and lower prevalence of tuberculosis treatment at ART start. For down-referred patients, 77%were down-referred after 6 months of ART. Over 5,198 person-years of ART, 107 adults died and 605 were LTFU. Attrition was 20% by 12 months; 3% had died and 16%were LTFU. Controlling for known confounders, down-referral was strongly protective against LTFU [adjusted hazard ratio (AHR) 0.38; 95% CI, 0.29–0.50] and attrition (AHR 0.50; 95% CI, 0.34–0.76) but not mortality. Compared with hub-initiated and maintained patients, spoke-initiated patients had lower LTFU (AHR 0.59; 95% CI, 0.45–0.77) and attrition rates (AHR 0.60; 95% CI, 0.47–0.77), but not mortality. Conclusions: Down-referral and spoke-initiation within a hub-and-spoke ART decentralization model were protective against LTFU and overall attrition and could facilitate future ART program expansion.

Oral Abstracts

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CROI 2015