CROI 2018 Abstract eBook

Abstract eBook

Poster Abstracts

dependence (aOR 1.65; 95% CI 1.05-2.60), and non-AIDS defining cancers (aOR 3.17; 95% CI 1.52-6.59) were all associated with mortality. Conclusion: Current cigarette smoking, alcohol dependence and other chronic diseases are strongly associated with mortality among PLWH in BC. Focused attention to smoking cessation, treatment for alcoholism and better diabetes management may further reduce mortality among PLWH.

higher with lower CD4 counts; at 12 months 32.2% (95%CI 31.8-32.6) of those with CD4<50 cell/mm 3 at ART start were lost or had died compared to 20.8% (95%CI 20.6-21.1) with CD4 101-200 cell/mm 3 (p<0.0001)(Table 1). In multivariable models, PLHIV with CD4<50 cells/mm 3 had 40% increased risk of attrition compared to those with CD4 101-200 cell/mm 3 (adjusted hazard ratio 1.4, 95%CI 1.3-1.4). Conclusion: Even after ART initiation, PLHIV with advanced disease had notably inferior outcomes within lower CD4 strata. With the transition of stable patients to less intensive DSD models requiring less provider time, the opportunity exists to focus on optimizing outcomes for PLHIV with advanced HIV disease. Novel DSD models that include biomedical, psychosocial and structural interventions are urgently needed.

899 HIGH MORTALITY AMONG PLHIV WITH TB IN LESOTHO DESPITE HIGH ART UPTAKE Andrea Howard 1 , Kieran Hartsough 1 , Kathryn Curran 2 , Koen Frederix 3 , Fred Asiimwe 4 , Llang Maama-Maime 5 , Simon G. Marealle 5 , Eric Pevzner 2 1 ICAP at Columbia University, New York, NY, USA, 2 CDC, Atlanta, GA, USA, 3 ICAP at Columbia University–Lesotho, Maseru, Lesotho, 4 CDC, Maseru, Lesotho, 5 Ministry of Health, Maseru, Lesotho Background: World Health Organization guidelines include the recommendation that people living with HIV (PLHIV) with tuberculosis (TB) should receive antiretroviral therapy (ART) as soon as possible within eight weeks of initiating TB treatment, and within two weeks if their CD4 count is <50 cells/µl. We evaluated the extent to which these guidelines were implemented and whether there was an impact on survival during TB treatment for PLHIV in Lesotho. Methods: We conducted a retrospective review of routinely collected clinical data from 25 purposively selected health facilities in five districts of Lesotho to evaluate ART uptake and TB treatment outcomes for PLHIV diagnosed with TB between January and June 2016. Descriptive and bivariate analyses were conducted. All statistical analyses accounted for clustering by health facility, using generalized linear mixed models. Results: Among 912 patients with TB/HIV we identified through record review, median age was 37 years (interquartile range [IQR] 31-45); 57%were male, 87%were new TB cases and 89% had pulmonary TB. Among 508 (56%) patients with available data, median CD4 count at TB diagnosis was 196 (IQR 93-344). Overall 783 (86%) were on ART during TB treatment. Of 751 patients with initiation dates, 315 (42%) were on ART prior to, and 436 (58%) started ART during TB treatment. Median time to ART initiation after TB treatment initiation was 17 days (IQR 14-29); 410 (94%) started ART within eight weeks, and 174 (40%) within two weeks of TB treatment initiation. Of 46 patients with CD4 count <50 who started ART during TB treatment, 22 (48%) started within two weeks of TB treatment initiation. Among all 912 patients, 27% achieved cure, 43% completed treatment, <1% failed treatment, 8%were lost to follow-up, 17% died and 5% had no TB treatment outcome recorded (Table). Mortality was higher among those with CD4 count <50 as compared to CD4 count ≥50 (25% vs. 11%, p=0.004) and among those who never started ART (54% vs. 14%, p <0.0001). There was no difference in mortality between those who started ART before vs. during TB treatment (15% vs. 13%, p=0.37). Conclusion: Over half of patients with TB/HIV were not on ART when diagnosed with TB. Despite high ART uptake during TB treatment, mortality was unacceptably high. Scale up of ‘Test and Treat’ holds promise as a TB prevention strategy for PLHIV. However, these findings support the critical need for an enhanced package of care for PLHIV with advanced disease to mitigate mortality among PLHIV with TB.

Poster Abstracts

898 PERSONS LIVING WITH HIV (PLHIV) WITH ADVANCED HIV DISEASE: NEED FOR NOVEL CARE MODELS Wafaa M. El-Sadr, Chloe A. Teasdale , Katharine Yuengling, Peter Preko, Maureen Syowai, Felix Ndagije, Miriam Rabkin, Elaine J. Abrams ICAP at Columbia University, New York, NY, USA Background: Differentiated service delivery (DSD) has highlighted the importance of developing diverse, patient-centered models of care for stable patients on antiretroviral therapy (ART). However, similar innovations are not yet available for PLHIV with advanced disease who are at high risk for poor outcomes and have received little attention beyond recognition of their need for prompt ART initiation. Methods: We analyzed data on PLHIV ≥15 years starting ART with CD4 cell count ≤200 cell/mm 3 at PEPFAR-funded ICAP-supported clinics in Ethiopia, Kenya, Mozambique and Tanzania 2004-2015. PLHIV with low CD4 at start of ART were divided into 3 groups: CD4 101-200, CD4 50-100 and CD4<50 cell/mm 3 to examine a combined endpoint of attrition (loss to follow up (LTF) and death) following ART start using Kaplan-Meier estimators and log-rank tests. LTF after ART initiation was defined as no visit >6 months; deaths were ascertained frommedical records. The combined endpoint was used as deaths are under- recorded. Cox proportional hazards models examined the effect of CD4 at ART start on attrition adjusted for sex, age, country and intrasite clustering. Results: 477,086 PLHIV started ART at 350 clinics, of whom 203,622 (42.7%) had CD4 ≤200 cell/mm 3 at ART start. Among these, 60.2%were female, median age was 35.0 years [IQR: 28.9-42.1], and 60.7%were WHO stage III/IV. Among those with CD4 <50 cell/mm 3 , 70.6%were stage III/IV compared to 52.9% of those with CD4 101-200(p<0.0001). Overall, for patients with CD4 ≤200, attrition at 3, 6 and 12 months was 14.8% (95%CI 14.6-14.9), 19.7% (95%CI 19.6-19.9) and 25.1% (95%CI 24.9-25.3), respectively. Attrition was significantly

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