CROI 2018 Abstract eBook

Abstract eBook

Poster Abstracts

887 ADVANCED HIV AND THE CARE CASCADE IN THE BOTSWANA COMBINATION PREVENTION PROJECT

Refeletswe Lebelonyane 1 , Lisa A. Mills 2 , Chipo Mogorosi 2 , Shenaaz El-Halabi 1 , Janet Moore 3 , Lisa Block 4 , Huisheng Wang 5 , Joe Theu 1 , Joseph Makhema 6 , Stembile Matambo 2 , Tafireyi Marukutira 2 , Etienne Kadima 6 , Max Kapanda 1 , Pamela J. Bachanas 3 , Joseph N. Jarvis 2 1 Botswana Ministry of Health, Gaborone, Botswana, 2 CDC Botswana, Gaborone, Botswana, 3 CDC, Atlanta, GA, USA, 4 Intellectual Concepts, Atlanta, GA, USA, 5 Northrop Grumman Corp, Atlanta, GA, USA, 6 Botswana Harvard AIDS Institute Partnership, Gabarone, Botswana Background: Individuals starting antiretroviral treatment (ART) with advanced HIV-disease (CD4 count ≤200 cells/µL) may have higher rates of early attrition from care due to HIV-related morbidity and mortality. We evaluated the impact of advanced HIV disease on treatment linkage and retention in a routine clinical setting in Botswana. Methods: The Botswana Combination Prevention Project (BCPP) is a cluster- randomized trial evaluating the impact of a combination prevention package on HIV incidence in 30 rural and semi-urban communities. This sub-analysis of the 15 intervention communities compares rates of linkage to care, ART initiation, retention in care, and virological suppression in patients identified through community testing between November 2013 and May 2016 with CD4 counts ≤200 cells/µL versus those with CD4 counts >200 cells/µL. Patients were eligible for ART if CD4 counts were ≤500 cells/µL or viral load ≥10,000 copies/ ml. Data were censored at the end of July 2017. Results: BCPP assessed HIV status in 44,223 individuals; 10,359 (23%) were HIV-infected, 2,706 (26%) of whomwere not on ART and were referred for HIV care. Of the 2,560 who had a point-of-care CD4 test, 519 (20%) had CD4 ≤200 cells/µL. 2041 (80%) had CD4 >200 cells/µL of whom 1578 were elgible for ART. Rates of linkage to care were lower in individuals with CD4 ≤200 cells/ µL compared to ART eligible individuals with CD4 >200 cells/µL (78% vs 88% at 6 months, p<0.001 and 93% vs 96% overall, p=0.005), as were rates of ART initiation (84% vs 89%, p=0.003). Mortality was 2.3% (12/519) in those with CD4 ≤200 cells/µL compared 1.1% (18/1578) with CD4 >200 cells/µL, p=0.05. By July 2017, 392 (76%) individuals in the CD4 ≤200 cells/µL were in care and on ART compared to 1301 (82%) with CD4 >200 cells/µL, p=0.001 (Table 1). Among those who initiated ART at least 6 months prior to data censoring, retention in care was 89% (365/408) in the low CD4 group and 93% (1,231/1,331) in the CD4>200 cells/µL group, p=0.05. Rates of viral suppression among those in care were similar in the two groups. Conclusion: Twenty percent of HIV-infected individuals not on ART had advanced HIV-disease. Those with advanced disease had lower rates of linkage to care, ART initiation, and retention in care, and higher mortality compared to healthier HIV-infected individuals. Once retained in ART care, rates of viral suppression were high. These data highlight the need to focus efforts on earlier identification of HIV-infected persons.

Poster Abstracts

888 IMPROVED VIRAL SUPPRESSION BUT STABLE MORTALITY IN PEOPLE WHO INJECT DRUGS, 1997-2015 Becky L. Genberg 1 , Gregory D. Kirk 1 , Jacquie Astemborski 1 , Hana Lee 2 , Shruti H. Mehta 1 1 Johns Hopkins University, Baltimore, MD, USA, 2 FDA, Silver Spring, MD, USA Background: People who inject drugs (PWID) face disparities in HIV treatment outcomes compared to other groups. While it is recognized that PWID may cycle in and out of care (and consequently viral suppression), less is known about whether the modern ART era has led to reduced transitions in and out of suppression for PWID. We used multi-state models to characterize mortality and transitions in and out of viral suppression from 1997-2015 among a community- based observational cohort of PWID. Methods: We included data from all HIV+ PWID in ALIVE (AIDS Linked to the IntraVenous Experience) in follow-up on or after 1997. We operationalized a multi-state model with the following states: detectable, suppressed, lost-to- follow-up (no visit > 9 months), and death. We examined changes in state transition probabilities over time, comparing early (1997-2004) and modern (2005-2015) ART periods. Results: Among 990 HIV+ PWID, median age was 43, 32% female, 93% African-American, 59% recently injected, and 54% died over a mean 10 years of follow-up. Probabilities of continued suppression, becoming detectable, or death when suppressed were: 0.54, 0.30, and 0.03 in the early period, and 0.78, 0.11, and 0.01 in the modern period, respectively (Figure). Probabilities of staying detectable, becoming suppressed, or death were: 0.70, 0.10, and 0.04 in the early period, and 0.64, 0.19, and 0.04 in the modern period, respectively. Adjusting for sex and race, transitions from detectable to suppressed increased over time in the early (relative risk ratio [RRR]=1.06, 95% CI:1.00-1.11) and modern (RRR=1.08, 95% CI:1.03-1.12) periods, and transitions from suppressed to detectable decreased in the modern era (RRR=0.89, 95% CI:0.85-0.93). The probability of death from both suppressed and detectable states in both periods remained stable over time. Recent injection was positively associated with suppression when detectable (RRR=1.88, 95% CI:1.44-2.45) and negatively associated with transitions from detectable to suppressed (RRR=0.49, 95% CI:0.41-0.59), but was not associated with death from either state. Conclusion: In the modern ART era, PWID experienced improved HIV treatment outcomes, with a higher probability of sustained suppression and transitions from being detectable to suppressed; however, these have not yet translated to reduced mortality even among suppressed PWID. Additional research is needed to understand stable mortality among HIV+ PWID despite drastic improvements in the modern ART era.

CROI 2018 337