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

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

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.

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

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

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

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

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

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

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

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.

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%

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%

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

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

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

Thank You

Retention in Care over Time In months since start of ART Cambodia89%84%61% Ghana87%81%77%68% Rwanda94%93%91%89%