CROI 2017 Abstract e-Book

Abstract eBook

Oral Abstracts

115 STRATEGIES TO ACHIEVE 90-90-90: MODELING INSIGHTS FROM ZIMBABWE Jack Olney , Jeffrey Eaton, Ellen McRobie, Timothy B. Hallett Imperial Coll London, London, UK

Background: To achieve the UNAIDS 90-90-90 targets by 2020, current HIV care programmes must be optimised. However, at present Zimbabwe and many other countries lack the ability to assess the prospect of achieving these goals. We used mathematical modelling to evaluate various strategies to achieve these goals, through implementing a range of interventions across the cascade over a five year period. Methods: To explore the ability of Zimbabwe to achieve these goals, we developed a novel mathematical model encapsulating the various stages of HIV care, and capable of utilising readily available data on the cascade to identify where resources are best allocated. Using historical data from Zimbabwe on HIV incidence, disease progression, treatment guidelines and the distribution of individuals across care, the model determined the current trajectory of care. We then estimated the achievement of the 90-90-90 targets in 2020, together with any changes to new infections and AIDS-related mortality, before determining strategies to improve patient outcomes, through implementing a range of interventions, each targeting a different aspect of care. Our web-based model can be applied to almost any country and will generate country-specific cascade reports to guide policy decisions around intervention implementation and investment opportunities to achieve 90-90-90. Results: Without intervention in the cascade, we estimated that in Zimbabwe between 2015 and 2020, an average of 14,529 individuals will initiate ART per year, 22,928 will drop out, and ART programme expenditure will cost an average of $346 million per year. However, to achieve the 90-90-90 targets, it will be necessary to initiate a further 10,990 individuals on ART and retain an additional 19,950 individuals in care annually, at a cost of an additional $25 million per year. Conclusion: To achieve future targets countries must maximise the efficiency of current treatment programmes. With decreasing public funding and the transition of many countries to solely funding their responses to the epidemic, current budgets must be better utilised. We demonstrate that in Zimbabwe, through analysis of the cascade, investments in ART care are recommended as the most efficient means of achieving the 90-90-90 targets by 2020. However, ART programmes in different settings should focus on improving data collection practices and analysing their individual cascades to tailor their response and guide policy toward these goals. 116 HIV CASCADE OF CARE INTERVENTIONS IN KENYA: CLINICAL IMPACT AND COST-EFFECTIVENESS Liem Binh Luong Nguyen 1 , Yazdan Yazdanpanah 1 , David Maman 2 , Stephen Wanjala 3 , Alexandra Vandenbulcke 4 , Elisabeth Szumilin 4 , William Hennequin 4 , Robert Parker 5 , Pierre Mendiharat 4 , Kenneth Freedberg 5 1 INSERM, Paris, France, 2 Epicentre, Cape Town, South Africa, 3 MSF, Nairobi, Kenya, 4 MSF, Paris, France, 5 Massachusetts General Hosp, Boston, MA, USA Background: In Southwest Kenya up to 24% of the adult population is HIV infected. Médecins Sans Frontières (MSF) has implemented a program to increase Voluntary Community Testing (VCT), linkage and retention to care, and ART coverage to achieve the WHO 90-90-90 targets by 2017. Our objective was to assess the clinical outcomes and cost-effectiveness of these interventions. Methods: We developed a time-discrete, dynamic microsimulation model to project outcomes in the general population (age 15-65 y). We modeled 4 strategies in 100,000 people: VCT (to 90% coverage), VCT + linkage to care (to 90% testing and 90% linkage in those HIV+), retention interventions (to 90% ART coverage in those linked and 90% virologic suppression on ART) and all 3 interventions combined. We used MSF data, other national data, and the literature for: HIV prevalence and incidence, non-HIV and HIV risks of death, risk of opportunistic infections, treatment efficacy, cascade of care, and cost of HIV care and interventions. We also calibrated uncertain data to the observed cascade of care in 2012: 62% tested, 57% linked, 40% suppressed. Cost data for VCT, VCT+ linkage, and the 3 interventions combined included start-up costs (€37,740, €75,480, €541,210 and €616,690; respectively), monthly fixed costs (€7,930, €12,540, €20,630 and €33,090) and variable costs. Outcomes included HIV incidence, years of life saved (YLS), cost (2014 €) and discounted Incremental Cost-Effectiveness Ratios (ICERs). We performed sensitivity analyses on key model parameters. Results: If implemented in 2014, after 15 years, VCT, VCT & linkage, retention interventions, and the 3 interventions combined increased outcomes from a base case of 69% tested, 66% linked and 31% suppressed to 73% to 94% tested; 66% to 93% linked, and 36% to 56% suppressed, depending on strategy. With current care, HIV incidence was 1.93/100 PY in 2029; the 3 interventions combined decreased incidence to 1.10/100 PY. For 100,000 individuals, the interventions combined cost € 40.2 million, led to 27,920 YLS, with an ICER of 320€/YLS compared to the base case. Baseline HIV prevalence and the interventions’ fixed costs had the biggest impact on the results. Conclusion: Interventions combining HIV testing, linkage and retention, and increased ART coverage would decrease HIV incidence by about half over 15 years. In rural Kenya, implementing these interventions together is substantially more effective and cost-effective than implementing them separately.

Oral Abstracts

117 A RANDOMIZED TRIAL OF READY-TO-USE SUPPLEMENTARY FOOD AT ART INITIATION IN AFRICA Jane E. Mallewa 1 , Alexander J. Szubert 2 , Jay Berkley 3 , Sanele Nkomani 4 , Abraham Siika 5 , Peter Mugyenyi 5 , Andrew Prendergast 6 , Sarah Walker 2 , Diana Gibb 2 , for the REALITY Trial Team 1 Malawi–Liverpool–Wellcome Trust Clinical Rsr Prog, Blantyre, Malawi, 2 Univ Coll London, London, UK, 3 KEMRI Wellcome Trust Rsr Prog, Kilifi, Kenya, 4 Univ of Zimbabwe Clinical Rsr Cntr, Harare, Zimbabwe, 5 Moi Univ, Eldoret, Kenya, 6 Queen Mary Univ of London, London, UK Background: Early mortality after antiretroviral therapy (ART) initiation is high among HIV-infected adults and children with severe immunosuppression in sub-Saharan Africa. Baseline malnutrition is common and increases mortality, but nutritional supplementation is generally only provided at ART initiation to those with severe malnutrition. Whether universal provision for those with advanced disease would improve nutritional status and reduce early mortality is unknown. Methods: The REALITY 2x2x2 factorial open-label randomized trial (ISRCTN43622374) enrolled ART-naïve HIV-infected adults and children ≥5 years with CD4<100 cells/mm3 from Kenya, Malawi, Uganda and Zimbabwe and ended in March 2016. This randomization compared initiating ART with/without 12 weeks of Ready-to-Use Supplementary Food (RUSF), providing 1000kcal/day with multi-vitamins/minerals. Those with severe malnutrition received Ready-to-Use Therapeutic Food (RUTF) regardless of randomization. Two other randomizations investigated 12-week raltegravir intensification or enhanced infection prophylaxis. The primary endpoint was 24-week mortality. Results: 1805 eligible adults (n=1733; 96.0%) and older children/adolescents (n=72; 4.0%) were enrolled, median age 36 years; 53.2%male; 53.7%WHO stage 3/4, and median baseline CD4 37 cells/mm3 (IQR 16-63). For those ≥13 years, median baseline weight was 53 (IQR 47-60) kg, BMI 19.3 (17.4-21.5) kg/m2 and MUAC 24.0 (22.0-26.1) cm. Participants were randomized to RUSF (n=897) or no RUSF (n=908) with ART. 25 (2.8%) and 39 (4.3%) respectively received RUTF, following local guidelines. Follow-up was 48 weeks (3.1% loss-to-follow-up). Gains in weight, BMI (Figure) and MUAC were greater in the RUSF group (p=0.004, 0.004, 0.03). Maximum differences were at 12 weeks; +3.8 RUSF versus +2.9

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CROI 2017