Changing Characteristics of HIVinfected Patients Initiating ART in East Africa 19982008

1
Changing Characteristics of HIV-infected
PatientsInitiating 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

2
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)

3
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

4
Adult and Pediatric Sites
5
Patients

• Selected all adults (gt18) 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

6
Clinics Contributing ART Initiators to Analysis
Since 1998
7
57,415 Patients Initiated ART Since 1998
Dramatic Increase after 2003 PEPFAR Roll-Out
7
11
30
143
8
Kenya
Patients Initiating HAART
Uganda
PEPFAR
Global Fund
Tanzania
MAP
Year of ART Initiation
9
Self Pay Era Ended in 2004
10
End of Self Pay Coincides With Dramatic Expansion
of ART Access
11
Changing Demographics of ART Initiators Over Time
12
Age of ART Initiators IsGradually Decreasing
Over Time
13
Women Account For an Increasing Proportion of ART
Initiators Over Time
14
Increase in Women Was More Notable in Uganda
Than in Kenya and Tanzania
Uganda
Kenya/Tanzania
15
Has the patients initiating ART at advanced
disease stages been changing over time?
16
Decreasing Patients Initiating ART with Stage
IV Disease
17
Decrease in WHO Stages III/IV at ART Initiation
Over Time
18
Nearly 60 of men initiated ART at WHO Stage III
or IV
19
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.
20
Women With Prior Hx PMTCT Initiated Therapy at
Less Advanced Disease Stage
21
CD4 Counts at ART Initiation Increasing in the
PEPFAR Era
22
What about opportunistic diseases among ART
initiators?Have these changed over time?
23
Despite initial decline, active TB remains very
common among ART initiators
24
Has the proliferation of HIV clinics providing
ART in East Africa led to measurable decreases in
the barriers to access ART?
25
Average Travel Time to Clinic Has Declined(Data
currently only available for Kenya)
26
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?
27
Apparent increasing delay to ART in patients with
WHO Stage III Disease, but still 1 month
28
No apparent increase in delay to ART for Patients
with WHO Stage IV Disease
29
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.

30
Conclusions (II)Continuing Challenges

• While patients are initiating therapy at earlier
  disease stages, most patients continue to start
  therapy late (CD4lt200).
• 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 gt2 hours to reach
  clinic.
• Desperately need to improve access for patients
  in rural areas

31
Acknowledgements
AMPATH Lameck Diero Sylvester Kimaiyo Samwel
Ayaya Winstone Nyandiko Edwin Sang Indiana
University Kara Wools-Kaloustian Paula
Braitstein Bill Tierney Beverly Musick
Constantin Yiannoutsos
FACES Elizabeth Bukusi Frankline Onchiri Patrick
Oyaro UCSF Cinthia Blatt Starley Shade Jayne
Kulzer Craig Cohen
Mbarara / MUST Mwebesa Bwana Nicholas
Musinguzi Winnie Muyindike UCSF Elvin Geng John
Bennett Megan Lazzar Jeff Martin Harvard
University / MGH Nneka Emenyonu David Bangsberg
IDI - Kampala Philippa Easterbrook Richard
Orama Agnes Kiragga Andrew Kambugu Damalie
Nakanjako Moses Kamya Masaka John Ssali
Morogoro Rita Lyamuya ORCI Hussein Mtiro
NACP G.R. Somi Roland Swai Tumbi Isaria Maruchu