CROI 2020 Abstract eBook

Abstract eBook

Poster Abstracts

Conclusion: While ART access and uptake have increased, higher 12-months attrition during the Same-day ART policy period may limit the benefits of the expanded ART program. However, participants who initiated ART on the day of diagnosis have improved viral suppression rates six months after starting ART.

97.9% (91/93) of the adult population achieved viral suppression with a median of 28 days from diagnosis. 92.5% (86/93) remained virally suppressed at 12 months post-diagnosis and 97.9% (91/93) remained engaged in care. There were no significant differences in these outcomes between the two groups. Conclusion: The intervention outcomes demonstrate that starting adults and youth on ART immediately after diagnosis, before labs are obtained, is safe, well-tolerated, and effective. Viral suppression was quickly achieved and maintained. Rapid Start is a paradigm shift that upholds equity and effectively engages youth.

1075 IMPACT OF UTT ON VIRAL SUPPRESSION IN SOUTH AFRICA: A NATIONAL COHORT STUDY Jacob Bor 1 , Matthew P. Fox 1 , Mhairi Maskew 2 , Dorina Onoya 2 , Alana T. Brennan 1 , Noah A. Haber 3 , Till Bärnighausen 4 , Sergio Carmona 5 , Wendy Stevens 5 , Adrian J. Puren 6 , William B. MacLeod 1 1 Boston University, Boston, MA, USA, 2 Health Economics and Epidemiology Research Office, Johannesburg, South Africa, 3 University of North Carolina at Chapel Hill, Chapel Hill, NC, USA, 4 Heidelberg University, Heidelberg, Germany, 5 National Health Laboratory Service, Johannesburg, South Africa, 6 National Institute for Communicable Diseases, Johannesburg, South Africa Background: Universal Test-and-Treat (UTT) aims to increase rates of viral suppression by extending treatment eligibility to all patients and reducing barriers to initiation of antiretroviral therapy (ART). Methods: We developed a national HIV cohort through novel linkage of the complete historical laboratory records of South Africa’s public sector HIV program, Apr 2004-Mar 2018. Using this cohort, we analyzed the longitudinal patient-level care cascade as observed through routine laboratory monitoring, and how it has changed over time within levels of presenting CD4 counts. Per national treatment guidelines, CD4 counts are collected when a patient first presents clinically with HIV. We analyzed progression from presentation (first CD4) to different stages of the HIV care cascade observed in the labs: an ART lab workup within 90 days of presentation (ALT/HG/CRT, taken prior to starting ART), HIV viral monitoring within 15 months of presentation (indicating a patient is on ART and retained in care), and viral suppression within 15 months of presentation. Patients were followed for 15 months to include routine viral loads at 6 and/or 12-months, with a 3-month buffer. Analyses were stratified by CD4 count at presentation and prevailing treatment guidelines at time of presentation. Results: 11M patients had a first CD4 count 2004-2016, including 266,479 in the UTT era (Sept-Dec 2016). The share of patients progressing from presentation to ART workup increased over time, from 46% before Aug 2011 to 91% under UTT. These gains were due in part to expansions of ART eligibility, leading to the elimination of discontinuities at prior CD4 thresholds, and in part to improvements affecting patients at all CD4 counts (Fig 1a). Eligibility expansions – and improved access to viral monitoring – also increased the share of patients progressing from presentation to documented viral suppression within 15 months (Fig 1b). Comparing the period just prior to UTT with the UTT era (Fig 1c), the share of patients presenting for care who had an ART workup increased from 78% to 91%; the share virally monitored increased from 54% to 61%; and the share reaching documented viral suppression increased from 38% to 44%. Conclusion: Despite high rates of progression from first CD4 to ART workup in the UTT era, many patients who present with HIV are not retained through viral monitoring and suppression. UTT has had a small impact on progression from clinical presentation to viral suppression.

Poster Abstracts

1074 TREAT-ALL HIV POLICIES AND PATIENT ATTRITION IN SOUTH AFRICA: A PROSPECTIVE STUDY Dorina Onoya 1 , Cheryl J. Hendrickson 1 , Tembeka Sineke 1 , Mhairi Maskew 1 , Lawrence Long 2 , Matthew P. Fox 2 1 Health Economics and Epidemiology Research Office, Johannesburg, South Africa, 2 Boston University, Boston, MA, USA Background: We aimed to determine whether the Universal Test & Treat (UTT) and same-day antiretroviral therapy (ART) policies, instituted in South Africa in September 2016 and 2017,resulted in improvements in patient attrition at 12-month after HIV diagnosis and viral suppression (<400 copies/ml) at six months after ART start. Methods: We enrolled three cohorts of newly diagnosed HIV infected adults from two primary health clinics in Johannesburg from April to November 2015 (Pre-UTT, n=144), May-September 2017 (UTT, n=178) and October-December 2017 (same-day ART period, n=88). A baseline survey was administered after HIV diagnosis and clinical records were reviewed up to 12 months after HIV diagnosis. We compared patient attrition, defined as being >90 days late for a visit (lost to follow-up (LTFU)) at 12-months, between HIV policy periods using Cox regression. Six-months viral suppression was assessed using log-binomial regression. Results: The median age among the 410 participants was 33.5 years (Intequartile range: 28.3-39.3), and 242 (56.9%) were female. Overall 172 (42.0% ) were LTFU at 12 months, 47.2% pre-UTT vs. 37.1% under UTT, and 43.2% under the same-day ART policy. Among those LTFU at six months, 92.4% were also lost at 12 months, whereas 29.9% of those in-care at six-months were LFTU at 12 months (34.3% pre-UTT, 26.9% under UTT and 29.6% during the same-day ART policy). However, when adjusted for ART uptake in the first 30 days, the same-day ART cohort was 60%more likely to incur losses at 12 months (adjusted hazard ratios (aHR) 1.6, 95% confidence intervals (CI): 1.0-2.6) than the pre-UTT cohort (Figure 1). Initiating ART 15-30 days (aHR 0.4, 95% CI: 0.1-1.0) after diagnosis had a 60% lower LTFU rate than starting ART on the day of HIV diagnosis. Having a baseline CD4>500 vs. <200 cell/mm 3 (aHR 1.6, 95%CI: 1.0-2.6) carried a higher risk of becoming LTFU at 12 months. However, among the 30-days ART initiates, initiating ART on the day of HIV diagnosis increased the likekelihood of viral suppression at six months (adjusted risk ratio 0.9 for 1-14 days ART vs. same-day ART, 95% CI:0.8-1.0).

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