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

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

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

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

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

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? Source: Kranzer et al (2010) 2 Rosen & Fox, PLoS Medicine 2011, in press

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

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

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

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. 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 (HE 2 RO), Wits Health Consortium, University of the Witwatersrand, Johannesburg, South Africa Acknowledgements