HIV System Assessment with Longitudinal Treatment Cascade in KwaZulu-Natal, South Africa Noah Haber,1 Frank Tanser,2 Kevindra Naidu,2 Tinofa Mutevedzi,2.

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HIV System Assessment with Longitudinal Treatment Cascade in KwaZulu-Natal, South Africa Noah Haber,1 Frank Tanser,2 Kevindra Naidu,2 Tinofa Mutevedzi,2 Deenan Pillay,2 Till Bärnighausen1,2 1 Harvard T.H. Chan School of Public Health 2 Wellcome Trust Africa Centre for Health and Population Studies HIV cascade is a key conceptual tool for understanding the pathway an HIV infected individual travels to go from infection all the way back to good health.

Introduction – Treatment cascade Global ART coverage increasing 63% ART coverage in developing world among eligibles (WHO 2013) Treatment cascade Assessment tool for health systems Identification of gaps and barriers Staged pathway from infection to immunological recovery Limitations of standard cross-sectional treatment cascade Multiple sources of data Longitudinal analysis limited to post-linkage to care Strong temporality assumptions 3/28/2015 HIV System Assessment with Longitudinal Treatment Cascade in KwaZulu-Natal, South Africa

Setting and data Setting Dataset ARTemis KwaZulu-Natal, South Africa Semi-rural, low income (Tanser, Hosegood, Bärnighausen, Herbst, Nyirenda, Muhwava, Newell, Viljoen, Mutevedzi, Newell IJE 2008) High HIV prevalence, ~30% (Zaidi, Grapsa, Tanser, Newell, Bärnighausen AIDS 2013) HIV incidence, ~3 per 100 person-years (Bärnighausen, Tanser, Gqwede, Mbizana, Herbst, Newell AIDS 2008) Dataset Africa Centre Demographic Information System (ACDIS) ARTemis 3/28/2015 HIV System Assessment with Longitudinal Treatment Cascade in KwaZulu-Natal, South Africa

“Cross-sectional” treatment cascade 3/28/2015 HIV System Assessment with Longitudinal Treatment Cascade in KwaZulu-Natal, South Africa

“Cross-sectional” vs. “longitudinal” treatment cascade 24,000 person-years Mean follow-up time 4.6 years 3/28/2015 HIV System Assessment with Longitudinal Treatment Cascade in KwaZulu-Natal, South Africa

Longitudinal treatment cascade (I) 3/28/2015 HIV System Assessment with Longitudinal Treatment Cascade in KwaZulu-Natal, South Africa

Longitudinal treatment cascade (II) 3/28/2015 HIV System Assessment with Longitudinal Treatment Cascade in KwaZulu-Natal, South Africa

Discussion Focus on major cascade losses Population changes over time Program changes over time UNAIDS 90-90-90 by 2020 Next steps 3/28/2015 HIV System Assessment with Longitudinal Treatment Cascade in KwaZulu-Natal, South Africa

Thank you Africa Centre community Africa Centre fieldwork and clinical staff Till Bärnighausen Deenan Pillay Kobus Herbst Günther Fink Funding: Wellcome Trust (Africa Centre), NIH/NICHD (R01 TB) Works cited WHO, Global Update on HIV Treatment 2013: Results, Impact, and Opportunities. 2013, World Health Organization. Tanser, Hosegood, Bärnighausen, Herbst, Nyirenda, Muhwava, Newell, Viljoen, Mutevedzi, Newell. Cohort Profile: Africa Centre Demographic Information System (ACDIS) and population-based HIV survey. Int J Epidemiol, 2008. 37(5): p. 956-62. Zaidi, Grapsa, Tanser, Newell, Bärnighausen. Dramatic increase in HIV prevalence after scale-up of antiretroviral treatment. Aids, 2013. 27(14): p. 2301-5. Bärnighausen, Tanser, Gqwede, Mbizana, Herbst, Newell AIDS 2008. High HIV incidence in a community with high HIV prevalence in rural South Afria: findings from a prospective population-based study. AIDS, 2008. 22(1): p. 139-44 3/28/2015 HIV System Assessment with Longitudinal Treatment Cascade in KwaZulu-Natal, South Africa

Appendix 1:Treatment cascade stages Event Definition First test positive Definition: First positive HIV test Estimation: First recorded positive HIV test in the ACDIS surveillance system Knows status Definition: Patient knows positive HIV status Estimation: First time patient says he/she knows status, or subsequent event Linked to care Definition: Patient engages with formal HIV-related health care Estimation: First recorded HIV clinic visit, registration at a clinic, CD4 test, viral load count, or initiate ARTs Eligible for ART Definition: Patient qualifies for ARTs, based on official guideline Estimation: Has CD4 count defined below Pre April 2010: CF4 count < 200 (or pregnant / TB) April 2010-July 2011: CF4 count < 200 (or pregnant/TB w/ CD4 < 350) August 2011 and after: CD4 count < 350 Initiate ARTs Definition: Initiation date of ART Estimation: Initiation date of ART Immunological recovery Definition: Virological suppression and/or immunological recovery Estimation: Recovery is estimated as having a CD4 count > 500 or a viral load undetectable levels 3/28/2015 HIV System Assessment with Longitudinal Treatment Cascade in KwaZulu-Natal, South Africa

Appendix 2: descriptive statistics First tested positive All 2006-2007 2008-2009 2010-2011 Female 0.73 0.71 0.74 (0.45) (0.44) Years of education 8.1 7.9 8.4 (3.6) (3.8) (3.7) (3.4) Married ever 0.27 0.3 0.26 0.25 (0.46) (0.43) Currently employed 0.31 0.34 0.29 (0.47) Pregnant ever 0.83 0.82 0.84 (0.38) (0.36) First CD4 Count 299 270 305 309 (222) (212) (230) (220) N 5,205 1,712 1,575 1,918 Note: mean (SD) 3/28/2015 HIV System Assessment with Longitudinal Treatment Cascade in KwaZulu-Natal, South Africa

Appendix 3: Status at first HIV+ detected 3/28/2015 HIV System Assessment with Longitudinal Treatment Cascade in KwaZulu-Natal, South Africa

Appendix 4: Continuous cascade 3/28/2015 HIV System Assessment with Longitudinal Treatment Cascade in KwaZulu-Natal, South Africa

Appendix 5: Cont. cascade w/ intercepts 3/28/2015 HIV System Assessment with Longitudinal Treatment Cascade in KwaZulu-Natal, South Africa