AIDSRelief: Optimizing the Durability of First line Treatment
20
UMSOM-IHV Division of Clinical Care & Research International Programs 1 AIDSRelief: Optimizing the Durability of First line Treatment Robb Sheneberger, MD Martine Etienne-Mesubi, PhD Mian B. Hossain, PhD Robert R. Redfield, MD University of Maryland School of Medicine Institute of Human Virology July 25, 2012
description
AIDSRelief: Optimizing the Durability of First line Treatment. Robb Sheneberger, MD Martine Etienne-Mesubi, PhD Mian B. Hossain, PhD Robert R. Redfield, MD University of Maryland School of Medicine Institute of Human Virology July 25, 2012. The AIDSRelief Consortium. AIDSRelief. - PowerPoint PPT Presentation
Transcript of AIDSRelief: Optimizing the Durability of First line Treatment
UMSOM-IHVDivision of Clinical Care & Research
International Programs1
AIDSRelief: Optimizing the Durability of First line Treatment
Robb Sheneberger, MDMartine Etienne-Mesubi, PhDMian B. Hossain, PhDRobert R. Redfield, MD
University of Maryland School of MedicineInstitute of Human Virology
July 25, 2012
The AIDSRelief Consortium
2
AIDSReliefOver the eight years of the program
Supported 276 mostly rural treatment facilities in ten countries
Delivered HIV care and treatment to 706,593 clients Initiated 395,088 patients on ART, including 268,631
currently on treatment at transition quarter
3
Durability of the Initial Regimen is the Key to Sustainability, Scalability and Long Term ARV Access to Global HIV Treatment Programs
Durability of Initial Regimen: Key Factors
Regimen Choice
Treatment Strategy
Care Delivery System
Durability of the Initial Regimen Systematic implementation of:
Regimen Choice Treatment Strategy Care Delivery Systems
Lack of durability shifts resources from these key areas reducing the ability to progressively improve outcomes
Continued improvement of treatment outcomes to the initial regimen remains a critical area
6
We used national guidelines but moved to greater durability as we were able to work with National governments to transition to more effective NRTIs
(i.e. TDF based regimens)
7
What we learned about: Regimen Choice
8
0.00
0.25
0.50
0.75
1.00
Pro
babi
lity
0 3 6 9 12 15 18 21 24 27 30 33 36Months
D4T/3TC/NVP D4T/3TC/EFV AZT/3TC/NVPAZT/3TC/EFV TRUVADA/NVP TRUVADA/EFV
PLO AIDSRelief: 2008Time to Switch to 2nd line Regimen
D4T/3TC/EFV
Truvada/NVP or EFV
N= 5199
What we learned about:Regimen Choice
With increased use of TDF based regimens an in-depth review showed:
On treatment analysis TDF/XTC/EFV had significantly higher odds of viral suppression than AZT/3TC/NVP (p<0.03) or TDF/XTC/NVP (p<0.01)
9
XTC=3TC or FTC
Amoroso, A, et al Treatment Outcomes of Recommended First-Line Antiretroviral Regimens in Resource-Limited Clinics JAIDS 1 July 2012 - Volume 60 - Issue 3 - p 314–320
N= 3862
What we learned about:Regimen Choice
10
Missed Appointments and Initial Regimen
Fewer people missed appointments on TDF compared to the other regimensN=7,513 p<0.004
What we learned about:Treatment Strategy
We used national guidelines but moved to greater durability as we were able to work with National governments to treat earlier
11
Baseline CD4 and viral suppression rates
Higher the initial CD4, greater the chances of increasing durability
12
What we learned about:Treatment Strategy
p<0.001
N=7,513
What we learned about:Treatment Strategy
WHO Stage at ART Initiation of Active Patients
WHO Stage at ART initiation of Care-ended Patients
13
N=1,762N=9,747
Mean Baseline CD4 over time, by cohort
140
50
100
150
200
250
300
350
400
450
Ken2006 Zam2006 Uga2006 Ken2007 Nig2007 Zam2007 Ken2008 Nig2008 Tan2008 Uga2008 Zam2008 Nig2009 Rwa2011 Nig2011
N=13,135
mean baseline CD4 c/mm3= 229
On Treatment Viral Suppression in Randomly Selected Patients 2006-2011
15
93.1
80
88.1
94.9
86.7
91.2 91.5
84 83.4
89 89.2 90.588.7
90.6
81.5
70
75
80
85
90
95
100
Avg=88.2
N=13,770
What we learned about: Care Delivery System
We had greater flexibility with the care delivery system and found that patients achieved greater durability in clinical settings that provided comprehensive treatment support, follow up and treatment education
16
What we learned about: Care Delivery Structure
Year 1- initial start up Year 5- follow up
17
n=27 sites; n= 13,391 persons
4.3% 4.1%
2.2%
0%1%2%3%4%5%6%7%8%9%
10%
Percent loss to
follow up
Tier I (
n=0)
Tier II
(n=20)
Tier III
(n=3
1)
Tier IV
(n=9
2)
n=143 sitesSites with fewer support systems had greater loss to follow up
Etienne, M et. al. Situational analysis of varying models of adherence support and loss to follow up rates; findings from 27 treatment facilities in eight resource limited countries; Trop Med Int Health. 2010 Jun;15 Suppl 1:76-81.
19
With consistent and systematic implementation of: Regimen Choice
TDF favored over D4T or AZT EFV favored over NVP
Treatment Strategy - starting early = better outcomes Care Delivery Systems - community based support
Durable viral suppression in the most rural settings is possible
Final Lessons Learned
Final Lessons We Are Learning The care delivery structure is profoundly critical
Overall loss to follow up rates have been increasing as funding as been decreasing
Insufficient investment made to support health care delivery structures to sustain optimal outcomes
The number of deaths, loss to follow up, and dropped out of care may hit critical levels where many of our gains will be lost, and care and treatment will become more complex and costly
20
Thank you!
21
