The first step is admitting you have a problem

1. The first step is admitting you have a problem Matthew Fox Center for Global Health & Development Department of Epidemiology Boston University July 17, 2011

2. Overview of Presentation • Defining the Problem • Stages of the Cascade • The Evidence for Retention by Stage • Pre-ART Care • ART Care • Conclusions • The Way Forward

3. How would an ideal HIV care and treatment program function? Disease Progression ART eligible Not ART eligible Ideal Program Progression Testing & Referral Determine ART eligibility Completion of referral Staging ART initiation Long term ART Monitoring Infection Actual Program Progression Testing & Referral Determine ART eligibility Completion of referral ART initiation Staging Long term ART Monitoring

4. Lifelong retention on treatment HIV+ population Part I: Losses from testing to treatment initiation Tested Staged Not tested ART eligible Not staged Initiate ART Not yet ART eligible Lost before ART initiation Retained through first year • Retained through ≈5 years Lost in first year • Retained 5-30+ years Pre-ART care until ART eligible Lost by 5 years Lost after 5 years Lost before ART eligible

5. From Testing to Treatment Initiation HIV+ diagnosed population Stage 3 ART eligibility to ART initiation CD4 count sample provided CD4 results obtained (staged) ART eligible Pre-treatment steps completed Initiate ART CD4 count sample not provided Lost before completing pre-treatment steps CD4 results not obtained (not staged) Lost before ART initiation Stage 2 Staging to ART eligibility Stage 1 Testing to staging Not yet ART eligible Enrolled in pre-ART care Pre-ART care until ART eligible Lost before enrolling in pre-ART care Lost before ART eligible

6. Summary of evidence • 18% continuously in care if no “recycling” • 33% in most complete study (South Africa)2 • Are only 1/5 to 1/3 of those who test HIV+ retained in care continuously? Rosen & Fox, PLoS Medicine 2011, in press Source: Kranzer et al (2010)2

7. It’s not just retention, but active engagement, timely completion of stages that is necessary Ingle et al. AIDS 2010

8. HIV+ population Tested Part II: Lifelong retention on treatment Staged Not tested ART eligible Not staged Initiate ART Not yet ART eligible Lost before ART initiation Retained through first year • Retained through ≈5 years Lost in first year • Retained 5-30+ years Pre-ART care until ART eligible Lost by 5 years Lost after 5 years Lost before ART eligible

9. Losses On ART: 2007 vs. 2010 60% Retention at 24 months 2010 Fox and Rosen, TMIH 2010 70% Retention at 24 months 2007Rosen, Fox and Gill PLoS Medicine 2007

10. What Happens to Patients Lost from ART Care? Brinkhof et al., PLoS One 2009

11. Unstructured Treatment Interruptions • Treatment interruptions common • To manage toxicity, treatment fatigue, etc. • Median % interrupting treatment was 23.1% • IQR: 14%-48% • Include developing and developed country data • Variable definitions of duration of treatment interruptions • Often undefined Kranzer and Ford, TMIH 2011, in press

12. The Way Forward • Better Measures of pre-ART Losses • Standard Definitions • Populations: Pregnant women, children • Investigate Reasons for Losses • Track Progress on Losses Over Time • Focus on pre-ART and Long Term ART • Develop/Target Intervention to Reduce Losses • Reducing visit time/number of visits, travel vouchers, relocate services, combine ANC/ART, same day ART initiation, reminders, provide pre-ART services (cotrimox, INH), incentives, etc.

13. Acknowledgements • U.S. Agency for International Development/South Africa (Melinda Wilson) • National Institute of Allergy and Infectious Diseases, U.S. National Institutes of Health • Boston University Center for Global Health & Development, Boston, USA • Health Economics and Epidemiology Research Office (HE2RO), Wits Health Consortium, University of the Witwatersrand, Johannesburg, South Africa