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Gradual increase in ART initiation following theimplementation of the new WHO
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Gabriela Patten 1 , Vivian Cox 1 , Kathryn Stinson 1,2 , Andrew Boulle 2 , Lynne Wilkinson 1 1 MSF Khayelitsha, 2 University of Cape Town The WHO 2010 revised adult ART guidelines recommended initiation of ART at a CD4 count of 350 cells/uL (previously 200) and for all co-infected with active TB or hepatitis B. These guidelines have been incrementally implemented in South Africa, with the raised threshold applied to those pregnant or TB co- infected from April 2010, then for all from August 2011, and ART regardless of CD4 for TB co-infected in April 2012. Raising the threshold was predicted to reduce HIV-related morbidity, mortality and transmission. Risks of implementation in resource-limited settings included increasing treatment costs, saturation of health service capacity, displacing patients in urgent need of ART and longer exposure to ART. Khayelitsha has a high HIV burden (37.1% antenatal HIV prevalence, 2011) and estimated good ART coverage, where ART is initiated at 11 primary care facilities. Among 22,782 adults accessing ART between 2007 and 2012, median age at initiation was 33 years and 68% were female. The proportion of men remained steady throughout the period at 32% (95%CI: 31%-33%). Men were more likely to access care with WHO stage 4 disease (Adjusted Risk Ratio=1.5, 95% CI: 1.4-1.6). Year-on-year increases in ART initiations from 2008 to 2012 were 34%, 30%, 20%, -2% and 14% respectively. ART initiations increased overall by 81% with median baseline CD4 counts rising from 135 cells/ul (95% CI: 131-140) to 221 cells/uL (95% CI: 217-226). The proportion with baseline CD4 count less than 200 cells/uL declined steadily from 80% in the first period to 44% in the last period. However, the total number of patients initiating ART with a baseline CD4 count < 200 cells/uL;100 cells/uL and 50 cells/uL remained constant (Figure 2). Gradual increase in ART initiation following the implementation of the new WHO guidelines in Khayelitsha, South Africa Background Author Contact: Gabriela Patten [email protected] Results Expanding ART eligibility criteria to a higher CD4 count threshold coincided with continued steady increases in enrolment with no sudden spike in ART initiations. More patients accessed care at earlier stages of disease without displacing This study assesses the impact of guideline changes to ART eligibility on the numbers and characteristics of adult patients initiating ART in Khayelitsha between 2007 and 2012. A cross-sectional analysis was undertaken using routinely-collected initiation data from 4 periods, the latter 2 coinciding with expanded eligibility criteria. and 50 cells/uL remained constant (Figure 2). The proportion of people initiating ART with stage 4 disease decreased from 21% to 11% (Figure 1), yet the total number remained constant over the 4 periods (Figure 2). Aims Methods Figure 2 Numbers of patients initiating ART per month according to baseline CD4 count category and WHO stage 4 disease in Khayelitsha, South Africa between 2007 and 2012 Conclusions 0 20 40 60 80 100 120 140 160 October 2007 - December 2008 January 2009 - March 2010 April 2010 - August 2011 September 2011 - October 2012 CD4: 100-200 CD4:50-100 CD4: 0-50 WHO Stage 4 Disease City of Cape Town Health Department Provincial Government of the Western Cape Health Department The dedicated staff at Khayelitsha clinics HIV positive members of the Khayelitsha community More patients accessed care at earlier stages of disease without displacing sicker patients with advanced disease. Trends in ART initiation are influenced by multiple demand and supply factors which lag behind policy changes, including community awareness and perception, gradual implementation and delays in expanding the service platform. Eligibility thresholds could be further raised without rapidly overburdening health care services in areas of good ART coverage. Figure 1 Trends in number of adult ART initiations per month, proportion with baseline CD4 count < 100 copies/uL, and with baseline WHO Stage 4 Disease in Khayelitsha, South Africa 2007-2012. The CD4 threshold for ART eligibility varied during the study period as follows: until March 2010, CD4 < 200; April 2010 to August 2011, CD4 350 for pregnant or TB-co-infected patients; September 2011-October 2012, CD4<350 for all patients Results Acknowledgements 0% 5% 10% 15% 20% 25% 30% 35% 40% 0 50 100 150 200 250 300 350 400 450 500 October 2007 - December 2008 January 2009 - March 2010 April 2010 - August 2011 September 2011 - October 2012 Average ART initiations per month Percentage initiated with Stage 4 Percentage initiated with CD4 count < 100
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Gabriela Patten, Vivian Cox, Kathryn Stinson, Andrew Boulle and Lynne Wilkinson
Transcript of Gradual increase in ART initiation following theimplementation of the new WHO
Gabriela Patten1, Vivian Cox1, Kathryn Stinson1,2, Andrew Boulle2, Lynne Wilkinson1
1 MSF Khayelitsha, 2 University of Cape Town
The WHO 2010 revised adult ART guidelines recommended initiation of ART at a CD4 count of 350 cells/uL (previously 200) and for all co-infected with active TB or hepatitis B. These guidelines have been incrementally implemented in
South Africa, with the raised threshold applied to those pregnant or TB co-infected from April 2010, then for all from August 2011, and ART regardless of CD4 for TB co-infected in April 2012.
Raising the threshold was predicted to reduce HIV-related morbidity, mortality and transmission. Risks of implementation in resource-limited settings included increasing treatment costs, saturation of health service capacity, displacing
patients in urgent need of ART and longer exposure to ART. Khayelitsha has a high HIV burden (37.1% antenatal HIV prevalence, 2011) and estimated good ART coverage, where ART is initiated at 11 primary care facilities.
Among 22,782 adults accessing ART between 2007 and 2012, median age at initiation was 33 years and 68% were female.
The proportion of men remained steady throughout the period at 32% (95%CI: 31%-33%). Men were more likely to access care with WHO stage 4 disease (Adjusted Risk Ratio=1.5, 95% CI: 1.4-1.6).
Year-on-year increases in ART initiations from 2008 to 2012 were 34%, 30%, 20%, -2% and 14% respectively.
ART initiations increased overall by 81% with median baseline CD4 counts rising from 135 cells/ul (95% CI: 131-140) to 221 cells/uL (95% CI: 217-226).
The proportion with baseline CD4 count less than 200 cells/uL declined steadily from 80% in the first period to 44% in the last period. However, the total number of patients initiating ART with a baseline CD4 count < 200 cells/uL;100 cells/uLand 50 cells/uL remained constant (Figure 2).
Gradual increase in ART initiation following the implementation of the new WHO guidelines in Khayelitsha, South Africa
Background
Author Contact: Gabriela [email protected]
Results
Expanding ART eligibility criteria to a higher CD4 count threshold coincided with continued steady increases in enrolment with no sudden spike in ART initiations.
More patients accessed care at earlier stages of disease without displacing
This study assesses the impact of guideline changes to ART eligibility on the numbers and characteristics of adult patients initiating ART in Khayelitsha between 2007 and 2012.
A cross-sectional analysis was undertaken using routinely-collected initiation data from 4 periods, the latter 2 coinciding with expanded eligibility criteria.
and 50 cells/uL remained constant (Figure 2).
The proportion of people initiating ART with stage 4 disease decreased from 21% to 11% (Figure 1), yet the total number remained constant over the 4
periods (Figure 2).
Aims
Methods
Figure 2 Numbers of patients initiating ART per month according to baseline
CD4 count category and WHO stage 4 disease in Khayelitsha, South Africa
between 2007 and 2012
Conclusions
0
20
40
60
80
100
120
140
160
October 2007 -December 2008
January 2009 -March 2010
April 2010 -August 2011
September 2011 -October 2012
CD4: 100-200 CD4:50-100 CD4: 0-50 WHO Stage 4 Disease
City of Cape Town Health Department
Provincial Government of the Western Cape Health Department
The dedicated staff at Khayelitsha clinics
HIV positive members of the Khayelitsha community
More patients accessed care at earlier stages of disease without displacing sicker patients with advanced disease.
Trends in ART initiation are influenced by multiple demand and supply factors which lag behind policy changes, including community awareness and perception, gradual implementation and delays in expanding the service
platform.
Eligibility thresholds could be further raised without rapidly overburdening health care services in areas of good ART coverage.
Figure 1 Trends in number of adult ART initiations per month, proportion with
baseline CD4 count < 100 copies/uL, and with baseline WHO Stage 4 Disease in
Khayelitsha, South Africa 2007-2012.
The CD4 threshold for ART eligibility varied during the study period as follows:
until March 2010, CD4 < 200; April 2010 to August 2011, CD4 350 for pregnant
or TB-co-infected patients; September 2011-October 2012, CD4<350 for all
patients
Results
Acknowledgements
0%
5%
10%
15%
20%
25%
30%
35%
40%
0
50
100
150
200
250
300
350
400
450
500
October 2007 -December 2008
January 2009 -March 2010
April 2010 -August 2011
September 2011 -October 2012
Average ART initiations per month
Percentage initiated with Stage 4
Percentage initiated with CD4 count < 100
