CROI 2017 Abstract e-Book

Abstract eBook

Poster and Themed Discussion Abstracts

1 Harvard Univ, Boston, MA, 2 Clinton Hlth Access Initiative, Mbabane, Swaziland, 3 Swaziland Ministry of Hlth, Mbabane, Swaziland, 4 Heidelberg Univ, Heidelberg, Germany Background: There is limited evidence on patient expenditures for antiretroviral therapy (ART) in the public-sector health systems in sub-Saharan Africa. This knowledge gap is becoming increasingly problematic as countries expand ART treatment eligibility, dramatically increasing the number of people eligible for ART. Carried out as part of the Early Access to ART for All (EAAA) health systems trial in Swaziland, this study aims to determine patients’ out-of-pocket expenditures for attending ART care in Swaziland. Methods: The study took place at 14 healthcare facilities, including high- and low-volume facilities and one regional hospital, in the Hhohho region of Swaziland from July 2014 to August 2016. We administered questionnaires in patient exit interviews on randomly selected clinic-days, eliciting data on costs for transport, food, consultation fees, medicines, child care, and phone calls, as well as on lost income due to time away fromwork. Costs in the local currency were converted to US dollars using the average exchange rate for the data collection period. Standard errors were clustered at the level of the healthcare facility. Results: The questionnaire was administered to a total of 742 patients. 25% (95% CI: 18–32%) of patients reported not having incurred any expenditure on the day of the interview. The average total out-of-pocket expenditure for an ART visit was $2.2 (95% CI: $1.5–2.8) across all interviewed patients, and $2.8 (95% CI: $2.1–3.5) for those who reported any expenditure. 11% (95% CI: 8–13%) of patients indicated that they lost income as a result of the time required to attend today’s ART visit-mean income loss was $34 (95% CI: $18–87). On average across all respondents, 56% of costs were incurred from lost earnings to attend the visit, 36% on transport to the clinic, 3% on food during travel, 2% on consultation fees, 2% on medicines, 1% on child care, and 1% on phone calls. Conclusion: Even though antiretroviral drugs are provided free-of-charge at the point-of-care in Swaziland’s public-sector health system, patients still incur large costs to attend ART care. Because travel and lost income are the largest financial burdens on ART patients, alternative delivery models that do not require travel and time-consuming clinic visits should be considered for future transformations of the HIV treatment response, e.g., differentiated ART with a community-based pathway for stable patients. 995 MARKED MORTALITY AND RETENTION UNDER-REPORTING IN A LARGE HIV PROGRAM IN ZAMBIA Charles Holmes 1 , Izukanji Sikazwe 1 , Ingrid Eshun-Wilson 2 , Nancy Czaicki 3 , Kombatende Sikombe 1 , Sandra Simbeza 1 , Carolyn Bolton Moore 4 , Cardinal Hantuba 1 , Nancy Padian 3 , Elvin Geng 5 1 Cntr for Infectious Disease Rsr in Zambia, Lusaka, Zambia, 2 Stellenbosch Univ, Cape Town, South Africa, 3 Univ of California Berkeley, Berkeley, USA, 4 Univ of Alabama at Birmingham in Lusaka, Zambia, 5 Univ of California San Francisco, San Francisco, CA, USA Background: Mortality and retention after entry into HIV care are crucial metrics of effectiveness of services in a region. However, under routine program conditions, deaths are underreported and overall estimates of mortality and retention and site-to-site variability in these outcomes may be biased. As a result, these vital metrics of performance cannot be reliably used for program improvement practices. Methods: We undertook a multi-stage sampling approach in which we selected a probability sample of facilities from a network of 70 facilities offering HIV care and treatment in Zambia, and then selected a simple random sample of lost patients within each facility for intensive vital status ascertainment. Deaths and in-care patients identified by tracing lost patients were used to revise overall outcome estimates through probability weights. Results: Among a cohort of 54,172 patients newly starting ART in 30 facilities (63%women, median age 35 years at enrollment (IQR: 29-42) and median ART initiation CD4 level of 266 cells/mm3 (IQR: 141-395)), 11,152 were lost to follow up over two years (20%). The median clinic-level loss to follow up was 26% (IQR: 22%-28%, range 20% to 40%). Among a random sample of 18% of all lost patients, 75% of outcomes were ascertained. Median clinic mortality among the lost across the 30 sites was 12% (IQR 8% to 17%, range 4% to 27%). Once outcomes among the lost were incorporated into overall estimates of mortality in the entire cohort, mortality at two years from ART rose from 2% (95% CI: 2% to 2%) to 9% (95% CI: 8% to 10%). Median site level mortality across the 30 sites was 9% (IQR: 5% to 15%, range 3% to 19%). The median ratio difference was 6% fold with IQR of 4-fold to 12-fold (Figure). Estimated retention across all sites was 61% at one year and 42% at two years, which rose to 86% and 78% upon incorporation of outcomes ascertained by tracing. Conclusion: Routine programmonitoring underestimated both mortality and retention outcomes, thus threatening to undermine assessments of public health effectiveness. A sampling based approach revealed that both the extent of underestimation and the actual revised mortality estimates differed markedly across facilities. Improved assessments of mortality and retention by facility can informwhere to target efforts for improved outcomes.

Poster and Themed Discussion Abstracts

996 DIFFERENTIAL UPTAKE OF HIV CARE AND TREATMENT BY SEXUAL RISK BEHAVIORS Veena G. Billioux 1 , Larry W. Chang 1 , Kate Grabowski 1 , Steven Reynolds 2 , Gertrude Nakigozi 3 , Joseph Ssekasanvu 1 , Robert Ssekubugu 3 , Ronald H. Gray 1 , Maria Wawer 1 , for the Rakai Health Sciences Program 1 The Johns Hopkins Univ, Baltimore, MD, USA, 2 NIAID, Washington, DC, USA, 3 Rakai Hlth Scis Prog, Kalisizo, Uganda Background: The success of treatment as prevention is dependent upon uptake of HIV care and antiretroviral therapy (ART). HIV-positive individuals who are not on ART are a potential source of HIV transmission. The sexual behaviors of persons who are not engaged in HIV care and treatment are poorly understood. We use empirical survey data to explore the association of risky sexual behaviors with uptake of HIV care and ART in Rakai, Uganda. Methods: 3,666 HIV-infected participants in the population-based Rakai Community Cohort Study (RCCS), surveyed between September 2013 and December 2015, provided self-reported information on engagement in care, ART use, and sexual behaviors. Engagement in care and treatment initiation was assessed using self-reports and clinical records. Prevalence risk ratios (PRR) of sexual behaviors and enrollment in care and ART initiation were estimated as using modified Poisson regression. Sex, age and community type (fishing, trading, and agrarian) were identified as potential confounders and were included in the multivariable models.

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