Changing Characteristics of HIV-infected Patients Initiating ART in East Africa 1998-2008

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. Mbale  AMPATH   • IDI • St. Francis • Mulago Masaka  FACES Nyanza Provincial Hospital Mbarara  Tumbi  Morogoro  Ocean Road Cancer Institute Adult and Pediatric Sites

5. 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

6. # Clinics Contributing ART Initiators to Analysis Since 1998

7. PEPFAR Global Fund MAP 57,415 Patients Initiated ART Since 1998 Dramatic Increase after 2003 PEPFAR Roll-Out 30 7 11 143

8. * ART supply interrupted 2ary MOH fraud * * 2008 data incomplete Kenya # Patients Initiating HAART Uganda PEPFAR Global Fund Tanzania MAP Year of ART Initiation

9. PEPFAR Global Fund MAP “Self Pay” Era Ended in 2004

10. PEPFAR Global Fund MAP 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. MAP Global Fund PEPFAR 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. MAP Global Fund PEPFAR 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 (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

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