1. Impact of IMPACT Patients’ Demographic Characteristics and Outcomes An analysis of FHI Initial ART Sites Philippe Chiliade, MD, MHA

2. Goals of the Analysis  Demographic characteristics of patients enrolled in FHI initial ART programs  Patients’ disposition: retained in care, lost to follow-up, known death, transfer out  Immunologic outcomes  Helping in moving forward

3. Data Sources (1) FHI started implementing ART programs with IMPACT funding in 4 countries: Cambodia, Ghana, Kenya, and Rwanda. Databases with baseline and follow-up patient-level data were created to monitor the characteristics of the populations served as well as the volume and outcomes of these ART services.

4. Data Sources (2) Countries and Sites selections: - Initial ART sites to allow longitudinal analysis - Reasonable completeness of data - Internal validation of data Data elements selections: - Demographics, disposition, CD4 - Similar definition of data elements

5. Limitations of the analysis  Retrospective data analysis  Sites were selected for their data quality  Little is known about the reasons and clinical outcomes of those lost to follow-up  Initial sites were often large secondary or tertiary health facilities

6. Selected FHI-supported ART Sites # Sites ART Start Date # Patients Cambodia15/031,362 Ghana45/035,844 Rwanda42/031,707

7. Patients Characteristics % male Age % WHO III or IV Baseline CD4 cells / mm3 Cambodia47%3594%59 Ghana37%3861%114 Rwanda36%3959%150

8. Patients Characteristics %female%maleAge % WHO III or IV Baseline CD4 cells / mm3 Cambodia53%47%3594%59 Ghana63%37%3861%114 Rwanda64%36%3959%150

10. Analysis of Care Disposition (1) Retention in care  In all 3 countries retention in care was related to baseline CD4 cell count  In Ghana and Rwanda, women are 33% less likely to be retained  In Ghana, any level of education was negatively related with retention

11. Analysis of Care Disposition (2) Known deaths  Over 70% of known deaths occurred within the first 6 months of ART initiation Lost to follow-up (LTFU)  Little is known about the reasons and clinical outcome of those LTFU

12. Immunologic Response  In all 3 countries the median CD4 of the cohort increased with time on ART.  That increase of CD4 over time was not driven by the removal from the cohort of sicker patients dying or being lost to follow-up.  After starting ART, the percentage of patients with CD4 < 50 and CD4 < 200 rapidly decreased.

14. Immunologic Outcomes % with CD4 < 50 At Baseline At 6 months At 12 months At 18 months Cambod.42%3%2%3% Ghana26%3%3%2% Rwanda14%

15. Immunologic Outcomes % with CD4 < 200 At Baseline At 6 months At 12 months At 18 months Cambod.84%48%36%31% Ghana75%28%18%15% Rwanda74%

16. The Way Forward (1)  Bring patients in care earlier, before their disease become too advanced  Need to better understand factors related to early death and lost to follow-up  Clinical and immunologic staging are adequate to inform when to start ART but virologic measures are key to monitor the response to ART

17. The Way Forward (2)  Monitor frequencies and patterns of drug resistance and use this information in the development of care guidelines  Develop (existing) local laboratory capacity  Monitor quality of care and adopt quality improvement approaches

18. Acknowledgements  FHI HQ Walter Obiero, Ya Diul Mukadi, Inoussa Kabore  FHI Cambodia Amrita Mathew, Ngak Song  FHI Ghana Yussif Ahmed Abdul Rahman, Richard Amenyah, Kwasi Torpey  FHI Rwanda Misti McDowell, Fabienne Shumbusho

19. Thank You

20. Retention in Care over Time In months since start of ART + 6 + 12 + 18 + 24 Cambodia89%84%61% Ghana87%81%77%68% Rwanda94%93%91%89%