CROI 2016 Abstract eBook
114 Towards the Second UNAIDS Target: Population-Level ART Coverage in HPTN 071 (PopART) Sarah J. Fidler 1 ; Sian Floyd 2 ; BliaYang 3 ; Kwame Shanaube 4 ; Peter Bock 3 ; Ab Schaap 4 ; Kaplana Sabapathy 2 ; Helen Ayles 2 ; Richard Hayes 2 ; for the HPTN_071 (PopART) StudyTeam 1 Imperial Coll London, London, UK; 2 London Sch of Hygiene & Trop Med, London, UK; 3 Univ of Stellenbosch, Cape Town, South Africa; 4 ZAMBART, Lusaka, Zambia Background: Background In 2014 UNAIDS set aspirational global targets for ART coverage for people living with HIV. Many countries currently fall below this target. HPTN 071 (PopART), a community randomised trial in Zambia and South Africa (SA), tests the impact on HIV incidence of a household-based combination HIV prevention approach provided by community-HIV-care-providers (CHiPs). CHiPs deliver universal testing; and for HIV-positive (HIV+) individuals support linkage to, and retention in, HIV care. ART is delivered through routine health care services. We present ART coverage after Round 1 of the intervention in 7 trial communities in which ART is offered to all HIV+ adults irrespective of CD4 count. Methods: The first round of intervention was from November 2013 to mid-2015. Among adults who consented to participate, those included in analysis are all who either self- reported they were HIV+ or they were newly diagnosed by CHiPs with a rapid HIV test. Among these adults who are known by CHiPs to be HIV+, our main outcome is the number and percentage on ART by the end of Round 1, among those still resident in the community at the time of the last CHiP follow-up visit. As part of understanding how this outcome was achieved, we used “time to event” methods to estimate the time to start ART after first referral to HIV care by CHiPs. Results: In Zambia 12,840, and in SA 3,300, adults were known by CHiPs to be HIV+ during Round 1. At the time of the first CHiPs’ visit, in Zambia 6,249 (49%) and in SA 1,712 (52%) reported they were taking ART; 5,108 (40%) and 1,242 (38%) respectively were newly diagnosed with HIV. Among those not taking ART, in Zambia 6,197 and in SA 1,385 were referred to HIV care; from a time to event analysis, by 12 months later 58% and 53% respectively had initiated ART. At the end of Round 1, in Zambia 80% and in SA 83% of all the adults who were known to be HIV+ were still resident in the same area of the community; 1-2% died and others had moved within (~7%) or outside (~10%) the community. Among those still resident, in Zambia 71% of men and 72% of women, and in SA 58% of men and 69% of women, were taking ART by the end of Round 1. Conclusions: Delivery of a home-based combination HIV intervention package conferred a substantial increase in population level ART coverage by the end of Round 1. The increase may be ongoing, as more adults link to HIV care, and as health promotion messages of universal treatment become more widely understood and accepted. 115 Optimising South Africa’s HIV Response: Results of the HIV and TB Investment Case Calvin Chiu 1 ; Gesine Meyer-Rath 2 ; Leigh F. Johnson 3 ;Tom Sumner 4 ;Teresa Guthrie 5 ;Yogan Pillay 6 ; Fareed Abdullah 7 ; Eva Kiwango 8 ; for the South African HIV andTB Investment Case TaskTeam and Steering Committee 1 Univ of the Witwatersrand, Johannesburg, South Africa; 2 Boston Univ, Boston, MA, USA; 3 Univ of Cape Town, Cape Town, South Africa; 4 London Sch of Hygiene & Trop Med, London, UK; 5 Guthrie Hlth Financing Consult, Cape Town, South Africa; 6 Natl Dept of Hlth, Pretoria, South Africa; 7 South African Natl AIDS Council, Pretoria, South Africa; 8 UNAIDS-South Africa, Pretoria, South Africa Background: South Africa’s burden of disease due to HIV and TB is large, as is the public sector response. We were tasked by the South African government, the main funder of the HIV and TB programmes, to recommend the optimal mix of interventions to reach national and global HIV and TB targets under limited funding. Methods: After a detailed review process, we selected 27 interventions, 9 factors increasing their technical efficiency, and 13 structural enablers impacting on HIV and/ or TB, and parameterised an integrated suite of models including Thembisa, a local HIV transmission model, TIME Impact, a Spectrum-based TB transmission model, and a cost model. For HIV, we analysed the cost effectiveness of the programme at baseline and at current government targets, and developed novel optimisation methodology to identify the most cost-effective combination of interventions under two scenarios: a) the current budget envelope and b) the UNAIDS 90-90-90 targets. We combined each of these with two different TB scenarios: a) baseline and b) the TB 90-90-90 targets. Cost effectiveness was measured as cost per life-year saved over 20 years. Results: Current government policy is relatively efficient but can be further improved (see Table). Under the current budget, the HIV programme could be optimised by scaling up cost-saving interventions (increasing condom availability and access to male medical circumcision and implementing social and behavioural change communication programmes that focus on increasing HIV testing uptake and discouraging multiple sexual partners) and spending the money thus saved on further scaling up ART. None of the technical efficiency factors except adherence clubs and home-based ART provision were found to be cost saving, and none of the examined structural enablers were able to compete with the other interventions on the basis of HIV endpoints- though both might be needed to reach the 90-90-90 targets. Results differ by province and district. Regarding the TB programme, targets will not be reached with HIV prevention and treatment alone; for this, a comprehensive package of TB and HIV prevention, intensified case finding, diagnosis and high quality treatment is required. Conclusions: Overall, the total cost of the HIV programme will increase regardless of the choice of interventions, but this cost could decrease in the next 10 to 15 years. The total cost of the TB programme however could be reduced after only 5 years of high investments in both the HIV and TB programmes.
116 Virologic Efficacy of ART Begun at High CD4+ Counts via Streamlined Care in East Africa Dalsone Kwarisiima 1 ;Vivek Jain 2 ; Asiphas Owaraganise 3 ; Florence Mwangwa 3 ; Dathan Byonanebye 4 ; James Ayieko 5 ; Maya Petersen 6 ; DianeV. Havlir 2 ; Moses R. Kamya; for the SEARCH Collaboration 1 Makerere Univ-Univ of California San Francisco Rsr Collab, Kampala, Uganda; 2 Univ of California San Francisco, San Francisco, CA, USA; 3 Infectious Diseases Rsr Collab, Kampala, Uganda; 4 Makerere Univ Coll of Hlth Scis, Kampala, Uganda; 5 Kenya Med Rsr Inst, Kisumu, Kenya; 6 Univ of California Berkeley, Berkeley, CA, USA Background: Overwhelming evidence supports ART for persons with high CD4 cell counts. However, treatment outcomes for adults with high CD4 counts in rural Africa have not been studied in large geographically diverse populations. We determined 48 week safety, retention in care, and viral suppression in adults with CD4≥350 in rural clinics in Uganda and Kenya using a nurse-driven streamlined ART delivery system. Methods: At 16 rural Ugandan and Kenyan clinics (SEARCH Study: NCT01864603) all HIV+ individuals were offered ART (TDF/FTC+EFV) regardless of CD4+ count. We studied adults (≥15 years) with CD4≥350 who initiated ART from June 2013-June 2014. Streamlined care included: (1) nurse-driven triage and visits focused on symptom-based ART toxicity screening, (2) on-site nurse referral of complex cases to a physician, (3) a patient-centered care system, fostering a welcoming/supportive environment, (4) viral load (VL)
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