484. Decreasing Time to ART Initiation after HIV Diagnosis in Sub-Saharan Africa
Session: Poster Abstract Session: HIV Care Continuum
Thursday, October 27, 2016
Room: Poster Hall
  • Crowell 42x84-A3.pdf (2.8 MB)
  • Background: World Health Organization (WHO) guidelines have shifted to recommend earlier initiation of antiretroviral therapy (ART). However, barriers to ART access may delay initiation in resource-limited settings. The objective of this analysis was to characterize temporal trends and other factors influencing the interval between HIV diagnosis and ART initiation in four African countries.

    Methods: The African Cohort Study enrolls adults engaged in care at 11 sites in Uganda, Kenya, Tanzania, and Nigeria. HIV-infected participants provide a medical history, complete a physical examination and undergo laboratory assessments every six months. Participants with recorded dates of HIV diagnosis were included in this analysis and categorized by WHO guideline era (<2006, 2006-2009, 2010-2012, or >2012) at the time of diagnosis. Factors associated with the time to ART initiation were explored using Cox proportional hazards models.

    Results: From January 2013-December 2015, 1555 HIV-infected adults enrolled and reported HIV diagnosis dates from 1994-2015. Participants had a median age at diagnosis of 35.2 years (interquartile range [IQR] 29.1-42.4) and 907 (58.3%) were women. The median interval between diagnosis and ART initiation decreased from 1.1 (IQR 0.2-6.3) years among individuals diagnosed <2006 to 0.8 (IQR 0.1-1.5) years among those diagnosed >2012 (p<0.001). In multivariable models, era was strongly predictive of shortened time to ART initiation, with a hazard ratio (HR) of 5.1 (95% confidence interval [CI] 3.8-6.7) for >2012 compared to <2006, after controlling for age, gender, country, religion, hepatitis status, and nadir CD4 count. Nadir CD4 was also strongly predictive, with <50 cells/mm3 associated with HR 9.1 (95%CI 6.8-12.1) as compared to >500 cells/mm3. The percentage of individuals initiating ART because of low CD4 decreased from 76.2% among those diagnosed <2006 to 45.2% among those diagnosed >2012 (p<0.001).

    Conclusion: Consistent with changing guidelines, the interval between diagnosis and ART initiation has decreased for HIV-infected individuals in this cohort. Still, many individuals initiate treatment with low CD4, highlighting the need to diagnose HIV earlier while improving access to immediate ART after diagnosis.

    Trevor Crowell, MD, PhD1,2, Christina Polyak, M.D., M.P.H.1,2, Peter Coakley, MB.BS2, Emmanuel Bahemana, MD3, Babajide Keshinro, MB;BS, FWACP4, Francis Kiweewa, MBChB, MMed, MPH5, Jonah Maswai, MD6, John Owuoth, MB.BS7 and Julie Ake, MD, MSc2, (1)Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, (2)U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, MD, (3)Walter Reed Program-Tanzania, Mbeya, Tanzania, United Republic of, (4)Walter Reed Program-Nigeria, Abuja, Nigeria, (5)Makerere University Walter Reed Project, Kampala, Uganda, (6)KEMRI/Walter Reed Project, Kericho, Kenya, Kericho, Kenya, (7)KEMRI/Walter Reed Project - Kisumu, Kisumu, Kenya


    T. Crowell, Gilead Sciences: Independent Contractor , Speaker honorarium

    C. Polyak, None

    P. Coakley, None

    E. Bahemana, None

    B. Keshinro, None

    F. Kiweewa, None

    J. Maswai, None

    J. Owuoth, None

    J. Ake, None

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