1. Matthew Fox Center for Global Health & Development Department of Epidemiology Boston University Health Economics and Epidemiology Research Office July 25 th, 2012 An Introduction to the Cascade of Care WEAE0201

2. How Do HIV Care and Treatment Programs Work? ART eligible Not ART eligible Disease Progression Infected Eligible for treatment Intended Program Progression Lifelong ART Pre-ART care Tested, assessed, enrolled ART initiated (CD4 ≈ 200/350) Waiting Eligibility established Lifelong ART Waiting Inaction Actual Program Progression Tested Eligibility established, enrolled ART initiated (CD4 ≤ 100) Symptom s

3. Retention from Testing through 2 Years on ART CD4 results not obtained (not staged) ART eligible Not yet ART eligible Initiate ART CD4 results obtained (staged) Lost before ART initiation Lost before ART eligible Pre-ART care until ART eligible HIV+ diagnosed population Staging to ART eligibility: 46% (range 31-95%) ART eligibility to ART initiation: 68% (range 14-84%) Testing to Staging: 59% (range: 35-78%) Lost to follow up On treatment through 2 years ART initiation through 2 years on ART: 60% - 70% Rosen PLoS Med 2011 Rosen PLoS Med 2007 Fox TMIH 2010

4. Summary of evidence Pre-ART estimates median retention 29% – 4 estimates (18% 1, 25% 2, 33% 3, 46% 4 ) – Most assume continuously in care, no “recycling” On ART retention at 2 years: 60-70% 5,6 – IeDEA-SA 1 year retention in declining over time% 7 1 Rosen & Fox, PLoS Med 2011 2 Mugglin CROI 2012 (1143) 3 Kranzer PLoS ONE 2010 4 Close AIDS Conference 2012 5 Rosen PLoS Med 2007 6 Fox TMIH 2010 7 Cornell AIDS 2010 Mugglin CROI 2012 (1143)

5. Outcomes for Lost Patients Ingle et al. AIDS 2010 Brinkhof et al., PLoS One 2009 pre-ART On ART

6. Conclusions Full retention from testing to long-term care difficult to estimate – Limited data on retention among those not ART eligible at testing until ART eligible Long term follow up data is needed Need for investment in better information systems Attrition from pre-ART care is highly problematic for earlier treatment initiation and treatment as prevention efforts – New strategies needed to reduce attrition