Changing Characteristics of HIV-infected Patients

Initiating ART in East Africa1998-2008

PW Hunt, K Wools-Kaloustian, S Kimaiyo, L Diero, WM Tierney, BS Musick, P Braitstein, P Easterbrook, C

Cohen, GR Somi, MB Bwana, E Geng, DR Bangsberg, JN Martin, and CT Yiannoutsos

For the East Africa IeDEA Consortium

East Africa

Background• ART programs have rapidly scaled up throughout East

Africa in the past 5 years

– Greatest pharmacologic intervention ever

• Roll-out has been dynamic, and change has been the rule

• Characteristics of ART initiators are likely to have changed in important ways in this rapid scale-up

• Understanding these changes may help in:

– Evaluating penetrance of the roll-out

– Interpreting effects of roll-out (treatment outcomes)

Objective• Among ART initiators in East Africa,

evaluate temporal trends in:

– Method of payment (self-pay vs free)– Distribution of age and gender– Proximity of residence to clinic– Stage of disease at initiation– Speed with which ART is initiated

East Africa

Adult and Pediatric Sites

Mbale

Masaka Mbarara

Ocean Road Cancer Institute

Morogoro Tumbi

AMPATH

FACES Nyanza Provincial Hospital

•IDI•St. Francis•Mulago

Patients

• Selected all adults (>18) initiating their first combination antiretroviral therapy (ART) regimen

• Women with prior ART use for PMTCT included

Analysis

• Stratified by year of ART initiation

• Assessed temporal trends in characteristics

# Clinics Contributing ART Initiators to Analysis Since 1998

57,415 Patients Initiated ART Since 1998Dramatic Increase after 2003 PEPFAR Roll-Out

PEPFAR

Global Fund

MAP

7 11 30 143

Year of ART Initiation

# P

atie

nts

In

itia

tin

g H

AA

RT

PEPFAR

Global Fund

MAP

Kenya

Uganda

Tanzania*

*

* 2008 data incomplete

ART supply interrupted 2ary MOH fraud

“Self Pay” Era Ended in 2004

PEPFAR

Global Fund

MAP

End of Self Pay Coincides With Dramatic Expansion of ART Access

PEPFAR

Global Fund

MAP

Changing Demographics of ART Initiators Over Time

Age of ART Initiators IsGradually Decreasing Over Time

Women Account For an Increasing Proportion of ART Initiators Over Time

Increase in % Women Was More Notable in Uganda Than in Kenya and Tanzania

Uganda Kenya/Tanzania

Has the % patients initiating ART at advanced disease stages been

changing over time?

Decreasing % Patients Initiating ART with Stage IV Disease

PEPFARGlobal Fund

MAP

Decrease in WHO Stages III/IV at ART Initiation Over Time

Nearly 60% of men initiated ART at WHO Stage III or IV

Women Much Less Likely To Initiate ART at Advanced Disease Stages

Consistent Trend Across All Years

PMTCT programs may allow for

diagnosis of women at earlier disease

stages.

Women With Prior Hx PMTCT Initiated Therapy at Less Advanced Disease Stage

CD4 Counts at ART Initiation Increasing in the PEPFAR Era

PEPFARGlobal Fund

MAP

What about opportunistic diseases among ART initiators?

Have these changed over time?

Despite initial decline, active TB remains very common among ART initiators

Has the proliferation of HIV clinics providing ART in East Africa led to measurable decreases in the

barriers to access ART?

Average Travel Time to Clinic Has Declined(Data currently only available for Kenya)

Have increasing numbers of patients starting ART strained clinic

capacity, introducing delays to initiate therapy?

Among patients who started ART, what was the average delay from WHO III/IV

diagnosis to ART initiation?

Apparent increasing delay to ART in patients with WHO Stage III Disease, but still ≤ 1 month

No apparent increase in delay to ART for Patients with WHO Stage IV Disease

ConclusionsThe Early Successes

• As ART programs have rolled out in East Africa:

– Dramatically more patients are accessing free therapy

– Access to clinics is improving (decreased travel time)

– More women are accessing ART

– Patients initiating therapy at less advanced disease stage

• These observations document a major early impact of the ART roll-out in East Africa.

• All of these factors should improve treatment outcomes over time.

Conclusions (II)Continuing Challenges

• While patients are initiating therapy at earlier disease stages, most patients continue to start therapy late (CD4<200).

– Need to re-double efforts to diagnose and get patients into care earlier.

• While TB prevalence among ART initiators may have decreased initially, it remains VERY common (~20%).

• While access to ART is improving, 1 out of every 6 patients is still traveling >2 hours to reach clinic.

– Desperately need to improve access for patients in rural areas

AcknowledgementsAMPATHLameck Diero

Sylvester Kimaiyo

Samwel Ayaya

Winstone Nyandiko

Edwin Sang

Indiana University

Kara Wools-Kaloustian

Paula Braitstein

Bill Tierney

Beverly Musick

Constantin Yiannoutsos

FACESElizabeth Bukusi

Frankline Onchiri

Patrick Oyaro

UCSF

Cinthia Blatt

Starley Shade

Jayne Kulzer

Craig Cohen

East Africa

Mbarara / MUSTMwebesa Bwana

Nicholas Musinguzi

Winnie Muyindike

UCSF

Elvin Geng

John Bennett

Megan Lazzar

Jeff Martin

Harvard University / MGH

Nneka Emenyonu

David Bangsberg

IDI - KampalaPhilippa Easterbrook

Richard Orama

Agnes Kiragga

Andrew Kambugu

Damalie Nakanjako

Moses Kamya

MasakaJohn Ssali

NACPG.R. Somi

Roland Swai

Tumbi Isaria Maruchu

MorogoroRita Lyamuya

ORCIHussein Mtiro