Variability in Populations Enrolled and their Outcomes in HIV Care and Treatment Programs Across Cou

1
Wafaa El-Sadr, MDInternational Center for AIDS
Care and Treatment ProgramsColumbia University
Mailman School of Public Health722 W. 168th
Street, room 709, New York, NY 10032E-mail
wme1_at_columbia.eduTelephone 212.342.0532Fax
212.342.1824
Poster Number 534
Variability in Populations Enrolled and their
Outcomes in HIV Care and Treatment Programs
Across Countries in Sub-Saharan Africa W.
El-Sadr, B. Elul, D. Nash, M. Hawken, J. Lima, D.
Macharia, B. Oluyden, R. Sahabo, B. Semo, M.
Zenebe, E. Abrams, J. Justman, M. Rabkin and D.
Hoos International Center for AIDS Care
Treatment Programs (ICAP), Columbia University
Mailman School of Public Health, New York, NY
BACKGROUND
Table 2 ART Regimens in Adults and Children by
Country, December 2006
Figure 1 Cumulative Enrollment in HIV Care and
ART Care and Total Number of Sites by Quarter
Figure 4 Proportion of Patients on ART by
Country (and range within country), December 2006

• Scale-up of HIV care and treatment has gained
  tremendous momentum over the past few years with
  successful enrollment of large numbers of
  HIV-infected patients in multiple
  resource-limited countries.
• To date, however, there has been little
  examination of differences in programmatic
  indicators across and within countries and their
  potential impact on patient outcomes.
• The International Center for AIDS Care and
  Treatment Programs (ICAP) at the Columbia Mailman
  School of Public Health supports HIV prevention,
  care and treatment programs in 14 countries,
  primarily in sub-Saharan Africa.
• Through funding from the Presidents Emergency
  Plan for AIDS Relief (PEPFAR) Track 1.0, ICAP
  supports HIV care and treatment programs,
  including provision of antiretroviral therapy
  (ART), when indicated, at 155 sites in 7
  sub-Saharan countries. The breadth of
  ICAP-supported programs allowed investigation of
  characteristics of patients enrolled and their
  outcomes across the various countries.
• We describe differences in populations and
  outcomes among 171,259 patients enrolled in HIV
  care and 71,482 patients on antiretroviral
  therapy (ART) in Ethiopia, Kenya, Mozambique,
  Nigeria, Rwanda, South Africa and Tanzania.

Figure 2 Cumulative Enrollment in HIV Care and
ART Care by Quarter and Country
Figure 5 Proportion of Women and Children in HIV
Care by Country (and range within country),
December 2006
Total in HIV Care (n171,259)
Total on ART (n71,482)
METHODS
Figure 9 Average Median CD4 count (cells/µL) at
Baseline and 6 and 12 Months after ART Initiation
by Country

• On a quarterly basis from July 2004 December
  2006, aggregate data on a standardized set of
  Office of the Global AIDS Coordinator (OGAC)
  indicators were collected by in-country
  Monitoring Evaluation Officers, transmitted to
  ICAP-New York via a web-based system and cleaned
  by New York-based staff.
• The primary data elements included in this
  analysis are as follows
• Cumulative number of patients enrolled in care
  and on ART by sex and age (i.e. lt15 vs. 15 years
  of age)
• Number of patients who received care in the last
  reporting period (October-December 2006) and were
  eligible for ART according to national
  guidelines
• Number of patients who were eligible for ART
  according to national guidelines and initiated it
  within three months
• Number of patients on specific ART regimens by
  age (i.e. lt15 vs. 15 years of age)
• Median baseline and 6-month follow-up CD4 cell
  counts for consecutive cohorts of patients gt6
  years of age initiating ART within a given
  quarter
• Median baseline and 12-month follow-up CD4 cell
  counts for consecutive cohorts of patients gt6
  years of age initiating ART within a given
  quarter and
• Cumulative number of ART patients known to have
  died or lost-to-follow-up.
• Descriptive statistics were used to compare
  demographic characteristics, ART status, and
  outcomes, including 6- and 12-month CD4 cell
  count change and death and lost-to-follow-up
  rates, among patients both within and across
  countries.
• As few sites have active outreach programs, the
  death and lost-to-follow-up rates are considered
  lower bound estimates.

Figure 6 Proportion of Women and Children on ART
by Country (and range within country), December
2006
Table 1 Number of Sites, and Cumulative Number
of PatientsEnrolled in HIV Care and ART Care by
Country, December 2006
Figure 7 Proportion of Patients Eligible for ART
by Country (and range within country), December
2006
Figure 10 Average Median CD4 count (cells/µL)
Increase after 6 and 12 Months of ART
Figure 3 Mean Number of Patients Enrolled Per
Site by Country (and range within country),
December 2006
Figure 11 Proportion of Patients who Died or
were Lost to Follow-up by Country (and range
within country), December 2006
Figure 8 Proportion of Patients Eligible for ART
who Initiated ART Within 3 Months of Eligibility
by Country (and range within country), December
2006
RESULTS

• From July 2004 through December 2006, a total of
  171,259 HIV infected patients were enrolled in
  HIV care and 71,482 were initiated on ART at 155
  sites in Ethiopia, Kenya, Mozambique, Nigeria,
  Rwanda, South Africa and Tanzania (Figures 1 2
  Table 1).
• The average number of patients enrolled in care
  at each site was 1,105 (range 17-9,916), and 461
  (range 0-3,555) for those who were initiated on
  ART (Figure 3). Sites in Ethiopia, Kenya,
  Mozambique and Rwanda have enrolled more than
  4,000 patients in care.
• Across ICAP-supported programs, 42 of enrolled
  patients have initiated ART (Figure 4). While
  substantial variation in the proportion of
  enrolled patients on ART is seen across
  countriesfrom 28 in Mozambique to 56 in
  Ethiopiain most countries, between 40-50 of
  patients have initiated ART. Significant
  variation is also observed in the proportion of
  patients on ART within countries, particularly in
  Nigeria, Rwanda and South Africa.
• Little variation is noted in the proportion of
  women and children enrolled in care and ART
  across countries, with women and children,
  respectively, accounting for 59 and 10 of all
  patients and 58 and 8 of ART patients (Figures
  5 6). Within country programs, however, there
  is great variability in the proportion of women
  and children enrolled in care and ART, with women
  accounting for as much as 80 of all patients and
  ART patients in some sites and some sites
  enrolling only pediatric patients.
• Among the 116,609 patients who received HIV care
  during the last reporting period
  (October-December 2006), 15 were eligible for
  ART according to national guidelines (Figure 7).
  The proportion eligible for ART ranged from 8 in
  Rwanda to 36 in Nigeria. Considerable variation
  in the proportion of patients eligible for ART is
  also observed within countries, with the
  exception of Rwanda where relatively few patients
  were eligible for ART at any site.
• Eligible patients initiated ART at varying
  rates, with only 47 of eligible patients
  initiating ART within 3 months in South Africa
  and 100 of eligible patients in Rwanda
  initiating ART within the same period (Figure 8).
  Most sites in Ethiopia and Rwanda initiated the
  majority of their patients on ART within 3 months
  of eligibility, while in other countries there
  was great variation by site in the initiation
  rates of eligible patients.
• Overall, nearly all adult (98) and pediatric
  (93) patients on ART are on first-line regimens
  (Table 2). In all countries but South Africa, the
  majority of adult ART patients are receiving
  d4T-3TC-NVP. In South Africa, d4T-3TC-EFV is the
  most common adult (86) and pediatric (62)
  regimen. Many pediatric patients in Ethiopia,
  Mozambique and Tanzania are receiving
  ZDV-3TC-NVP.
• Among successive cohorts of patients gt6 years of
  age initiating ART, CD4 cell count at the time of
  ART initiation was low across countries,
  particularly in Ethiopia, Kenya and South Africa,
  and ranged from 104 to 198 cells/mm3 (Figure 9).
  As shown in Figure 9, after 6 months on ART, the
  average median CD4 cell count across countries
  was 246 cells/mm3 with little variation by
  country (range 223-290 cells/mm3 ). After 12
  months on ART, there was a universal substantial
  increase in CD4 cell count across countries and
  the average median CD4 cell count was 291
  cells/mm3 (range 277-305 cells/mm3). As depicted
  in Figure 10, the average increase in median CD4
  cell count after 6 and 12 months of ART across
  countries was 116 and 149 cells/mm3,
  respectively. 6- and 12-month response was the
  most modest in Rwanda (6-month increase 70
  cells/mm3 12-month increase 90 cells/mm3).
• The proportion of ART patients known to have
  died was low and similar across countries at
  5-6, although in some sites in Ethiopia and
  Mozambique, more than 15 of ART patients are
  known to have died (Figure 11). The proportion of
  patients lost-to-follow-up ranged from 1-17
  across countries. At some sites in Kenya,
  Tanzania and South Africa, however, more than 20
  of patients were lost-to-follow-up. Person-time
  on ART at each site was not taken into account.

CONCLUSIONS
ACKNOWLEDGEMENTS

• Patients are receiving HIV care and treatment
  services at facilities with both small and large
  patient caseloads
• The establishment of services in diverse
  settings (i.e. urban tertiary facilities vs.
  rural primary health centers) likely explains
  some of the variability in the number of patients
  per site, as does program maturity with newer
  sites having fewer patients
• Variability across sites and countries was noted
  in characteristics of patients enrolled,
  particularly in the proportion eligible for and
  on ART
• Differences in the proportion of patients
  eligible for and on ART by country likely reflect
  differences in the source of referrals with, for
  example, the majority of patients in Mozambique
  believed to be coming from VCT services and, thus
  at earlier stages of HIV infection compared to
  other countries were a higher proportion of
  patients are identified through provider
  initiated testing in in-patient wards
• Specialized sites catering to pediatric patients
  in Mozambique and female genocide survivors in
  Rwanda account for the high proportions of
  pediatric and female patients enrolled in care
  and on ART at some sites
• Most patients were still on first-line ART
  regimens
• In adults most commonly used first-line ART
  regimen is stavudine, lamivudine and nevirapine
  while South Africa uses stavudine, lamivudine and
  efavirenz as a first-line regimen
• In children most commonly used first-line ART
  regimen is stavudine or zidovudine, lamivudine
  and nevirapine while South Africa utilizes
  stavudine, lamivudine and efavirenz as a
  first-line regimen
• Substantial 6- and 12-month CD4 cell count
  response was observed consistently across
  countries
• Survival among those who initiated ART was
  excellent and most patients remained in care,
  although passive outreach at most sites likely
  led to an underestimate of the death and
  lost-to-follow-up rates
• Sites with higher death and lost-to-follow-up
  rates tend to be those that have been offering
  services for longer periods of time
• Little is known about pre-ART patient outcomes,
  particularly among those eligible for ART where
  death rates may be very high
• There are differences in implementation of
  programs that may also affect variation in
  patient outcomes, both pre-ART and ART. More
  detail on facility and program characteristics to
  examine their influence on patient outcomes
  should be included in future analyses.

Partners organizations including Federal
Ministry of Health, Ethiopia Ministry of Health,
Nigeria Indiana University, Moi University,
Ministry of Health, Kenya Ministry of Health,
Mozambique Treatment and Research AIDS Center,
Ministry of Health, Rwanda Provincial Health
Department of the Eastern Cape, South Africa
Ministry of Health, Tanzania Government staff at
the 155 ICAP-supported sites ICAP staff
in-country and in New York, particularly Mr.
Wilson Lo and Ms. Deb Horowitz CDC and USAID
staff in the United States and Africa, including
Dr. Tedd Ellerbrock The individuals and families
with HIV receiving services at ICAP-supported
sites Funding support United States Centers for
Disease Control and Prevention (CDC) and the
United States Agency for International
Development (USAID)
ICAP supports 14 countries in sub-Saharan Africa
and Asia.