CROI 2016 Abstract eBook

Abstract Listing

Oral Abstracts

measurement and structured VL counseling, (5) provision of 3 months’ ART refills, and (6) appointment reminders and patient tracking. Patients had visits at baseline, week 4 and 12, then every 12 weeks. VL was assessed at baseline, 24 and 48 weeks, along with basic safety laboratory tests, and 48-week virologic suppression was calculated as the % of persons with a measured week 48 VL ≤500 copies/mL (complete case analysis). Results: Overall, 964 HIV+ adults with CD4≥350 initiated ART. Median age was 33 years, 66%were female, median baseline CD4 was 607 cells/uL (IQR, 486-787/uL), and median baseline VL was 3.80 log copies/mL. At week 48, 874/964 (91%) of patients were retained (2 died, 28 moved, 8 withdrew, and 52/964 [5%] were lost to follow-up). Viral suppression was achieved in 748/800 (94%) with measured VL. Overall, grade III/IV clinical or laboratory adverse events (AE) were rare: 79 occurred in 63/964 (6.5%) patients. Top clinical AEs were fever (n=7) and dizziness (n=4). The most common laboratory AE was neutropenia (n=16, all asymptomatic). Overall, 9/964 (0.9%) persons switched ART from EFV to RTV/LPV (n=2 for dizziness, n=2 for gynecomastia, and n=5 for other reasons). Conclusions: We found high viral suppression, retention in care and safety of ART delivered via a streamlined care system in East African adults with high CD4+ cell counts. These results amplify growing evidence that ongoing expansion of ART to asymptomatic adults with high CD4+ counts can be accomplished in rural resource-limited Sub-Saharan clinics using efficient, nurse-driven care models. 117 HIV Mortality by Care Cascade Stage and Implications for Universal ART Eligibility Eran Bendavid 1 ; Anna Bershteyn 2 ; Andrew Boulle 3 ; Jeffrey W. Eaton 4 ;Timothy Hallett 4 ; Daniel J. Klein 2 ; Jack J. Olney 4 ; Andrew N. Phillips 5 ; Emma Slaymaker 6 ; for the HIV Modelling ConsortiumWriting Group on ART Eligibility Guidelines 1 Stanford Univ, Stanford, CA, USA; 2 Inst for Disease Modeling, Bellevue, WA, USA; 3 Cntr for Infectious Disease Epi and Rsr, Cape Town, South Africa; 4 Imperial Coll London, London, UK; 5 Univ Coll London, London, UK; 6 London Sch of Hygiene & Trop Med, London, UK Background: A decade after the scale up of ART in southern and eastern Africa, mortality rates among HIV-positive adults remain 3-6 times higher than in HIV-negative adults. Prioritising interventions for improving HIV care requires information about the care stages where most deaths arise, and thus where the greatest gains could be made. Immediate ART eligibility may fundamentally reshape the care cascade by removing the ‘pre-ART care’ stage where high dropout has been documented. Methods: We reviewed empirical data and mathematical modelling estimates about mortality across stages of HIV care. Empirical estimates came from linked clinical and vital registration data fromWestern Cape, South Africa, and population cohorts in Uganda, Malawi, and South Africa. We used four mathematical models calibrated to HIV epidemics and care and treatment utilization in Rwanda, Kenya, Malawi, and South Africa. Models estimated the distribution of HIV deaths occurring at each stage of care and projected this over the next decade assuming continuation of current patterns of HIV care uptake and retention. Three models simulated the effects of changing guidelines to immediate ART initiation for all patients linked to care, assuming that retention would be similar to current levels. Results: Only 10–30% of HIV-related deaths are estimated to occur among patients who are continuously on ART for 6 months or more. At present, the majority of HIV deaths occur among patients who did not initiate ART (Figure). Patients disengaging from ART have a high mortality rate, and models show that this will account for an increasing and substantial share of HIV deaths (21–44% in 2025). Assuming continuation of current care patterns, models projected that between 9% and 22% of HIV deaths from 2016–2025 would occur among patients who had linked to care but never initiated ART. Immediate ART initiation could reduce HIV deaths by between 6–14% over 2016–2025, mostly due to removing the opportunities to disengage before treatment initiation. Conclusions: Even in settings with high ART coverage, the majority of HIV-related deaths are likely to continue to be among patients who are not on ART, rather than patients who are stable on ART. Programmes should continue to prioritise interventions to link and retain patients to and on ART. Universal eligibility for ART initiation may bring substantial benefits through the simplification in the care cascade.

Bendavid - Rwanda

Olney - Kenya

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Oral Abstracts

Undiagnosed Diagnosed, never linked Not in care, previously linked Pre-ART care

ART naive Initiated ART

ART naive Initiated ART

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Synthesis - Malawi

EMOD - South Africa

ART < 6 months ART > 6 months Dropped out ART

ART naive Initiated ART

ART naive Initiated ART

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Trends in ART Discontinuation by Age in Malawi, 2004–2014 Catrina A. Mugglin 1 ; Andreas Haas 1 ; Joep van Oosterhout 2 ; Frank Chimbwandira 3 ; LysonTenthani 1 ; Malango Msukwa 4 ; Oliver Gadabu 5 ; Janne Estill 1 ; Matthias Egger 6 ; Olivia Keiser 1 1 Inst of Social and Preventive Med, Univ of Bern, Bern, Switzerland; 2 Dignitas Intl, Zomba, Malawi; 3 Malawi Ministry of Hlth, Lilongwe, Malawi; 4 Inst of Social and Preventive Med, Univ of Bern, Lilongwe, Malawi; 5 Baobab Hlth Trust, Lilongwe, Malawi; 6 Univ Hosp Bern, Bern, Switzerland Background: In Malawi, the number of people alive on antiretroviral therapy (ART) increased from 10,761 in 2004 to 521,319 by the end of 2014. Long term outcomes remain incompletely understood. We analysed time trends of ART discontinuation rates across all age groups. Methods: Our prospective cohort analysis of individual patient data from 20 large health care facilities with an electronic medical record (EMR) system in central and southern Malawi included data from all patients who started ART for the first time between 2004 and 2014. Follow-up time was split by age (10 groups, see Figure), calendar period according to changes in ART guidelines (4 periods, see Figure), and time since start of ART (<1 year, ≥1 year). We calculated time from ART initiation to discontinuation due to death, loss to follow-up (LTFU) or any other reason, or to database closure, whichever came first. LTFU was defined as patients not seen for >150 days after the first missed appointment. Patients with documented transfer out were excluded. Discontinuation rates and 95% Poisson confidence intervals were calculated per 1,000 person-years of follow-up (PYFU). Results: Of 127,316 individuals included in the analysis 62%were female and the median age was 32 years. During 161,112 PYFU there were 75,472 discontinuation events (6,660 deaths, 68,685 LTFU, 127 other). Median follow up time for the ≥ 1 year analysis was 2.7 years (range 1-8 years). The Figure shows discontinuation rates by age and time period.

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CROI 2016