Retention to care-The Achilles heal of HIV treatment

Suresh

Fox MP, Rosen S (2017) A new cascade of HIV care for the era of “treat all”. PLOS Medicine 14(4): e1002268

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SureshAIDS Res Hum Retroviruses. 2011 Jul;27(7):751-8

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Importance of retention

Missing = failure

Intention to treat analysis

On treatment analysis

SureshJAMA Intern Med. 2015;175:588-96.

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Overall Outcome (Excluded Transfer Out)

1 Year = 5664 2 Years = 4905 3 Years = 4052 4 Years = 3169 5 Years = 2454

Others 0.5% 0.3% 0.2% 0.6% 0.4%

Death 2.9% 4.1% 5.2% 6.4% 7.6%

LTFU 6.7% 9.9% 12.8% 13.8% 14.9%

SLR 0.6% 2.0% 3.5% 4.0% 4.1%

FLR 89.4% 83.7% 78.3% 75.3% 72.9%

0%

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20%

30%

40%

50%

60%

70%

80%

90%

100%

Defaulter Profile, 2015

ART Naive ART Experienced

< 6 months on ART – 81 (27%)

> 6 months on ART – 217 (73%) 125 (58%) - VL suppressed

53 (24% )- VL > 1000 copies

39 (18%) – VL missing

Total number of ‘No Show’ – 3252

True defaulters – 473 (15%) ART Naïve – 175 (37%)

ART Experienced 298 (63%)

50 (29%) – Cd4 count <350

125 (71%) – Cd4 count >350

Suresh

Fox MP, Rosen S (2017) A new cascade of HIV care for the era of “treat all”. PLOS Medicine 14(4): e1002268

Suresh

“went to the OPC in order to receive medicine [ART ]. I wondered why they did not give me ART when other people got it. Then I asked Mr. X. [a health care staff member], he said that my CD4 count was still high so I did not need to take ART”

Suresh

Same day initiation of ART

PLoS Med. 2017 Jul; 14(7): e1002357.

Defaulter Profile, 2015

ART Naive ART Experienced

< 6 months on ART – 81 (27%)

> 6 months on ART – 217 (73%) 125 (58%) - VL suppressed

53 (24% )- VL > 1000 copies

39 (18%) – VL missing

Total number of ‘No Show’ – 3252

True defaulters – 473 (15%) ART Naïve – 175 (37%)

ART Experienced 298 (63%)

50 (29%) – Cd4 count <350

125 (71%) – Cd4 count >350

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Appointment keeping adherence - 2016

3298 – ‘No Show’

465 (14%) – True defaulters

Managed to contact – 77 (17%)

Could not contact – 373 (83%)

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Why did you default?

conflicting demands/Unmet needs

49%

prison/incarceration20%

patient15%

clinic11%

others5%

Dr Yasmin Gani

Suresh

Structural barriers

Structural barriers stem from material conditions of life in resource-limited settings

Unmet needs Conflicting demands Prison/incarceration

Transportation costs Work responsibilities

No money Child care commitments

Too far Family accident

Pregnancy, childbirth

Did you have any difficulty coming to clinic today?Is there anything I can do to help?

Gardner, Clin Infect Dis. 2012 Oct;55(8):1124-34

Suresh

Why did you default?

conflicting demands/Unmet needs

49%

prison/incarceration20%

patient15%

clinic11%

others5%

Dr Yasmin Gani

“I felt healthy”

Suresh

Why did you default?

conflicting demands/Unmet needs

49%

prison/incarceration20%

patient15%

clinic11%

others5%

Dr Yasmin Gani

“Could not tolerate side-effects”

Suresh

“In 2007, I got sick and had to be hospitalized. When I got better, they [doctors] prescribed me ARV drugs. However, when I took them, I felt nausea, vomited and often had nightmare. I was even not able to sleep. I was so scared and stopped taking drugs. I have stopped taking them for about one year.”

“I took these pills and they made me feel dizzy. I could not walk and would crawl to bed and I would see the house going in circles but I came back here they encouraged me to continue taking the pills." (Female, on ART <5 years, Zimbabwe)”

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"After I had taken the ARVs, my hands had peeled and my feet … I visited the doctor twice and they would say I should continue to take my medication. So I just wondered if I was safe because of the continuous reaction, so I stayed at my home and I stopped taking the medication."(Female, LTFU, Zimbabwe)

Suresh

“I gave up ARV because I took methadone at the same time. When I took methadone and ART together, it made me feel very hot inside my body. I lost weight. My body was very dry, my lips were cracked, and I got diarrhea too. So I decided to stop taking ARV.”

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“One size fits all” to “differentiated care”

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Positive wellness clinic

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Down-referral and task-shifting

Stable

Art for 11 months

No opportunistic infections

Stable weight

CD4 count > 200

Virally suppressed, x 2 (4months apart)

Down referred vs patients eligible but not down referred (due to refusal or not done)

Down referred patients

Lower mortality HR 0.2, CI 0.04 – 0.8

Lower LTF – HR 0.3, CI 0.2-0.6

Lower Viral rebound – HR 0.6, CI 0.4-0.9

Reasons for up-referral LTFARV toxicityPregnancyDetectable VLOpportunistic infection

AIDS. 2011 October 23; 25(16): . doi:10.1097/QAD.0b013e32834b6480.

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Positive wellness clinic

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Task shifting – Positive wellness clinic

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Tele clinic

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After office hours

Saturday clinic

After office hours drug pick up

Pos Laju

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For the patients who need more than routine care

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“Participants will be more likely to enrol in interventions that protect their confidentiality, to attend when scheduling is responsive to their needs, and to both attend and continue with an intervention when they develop a strong, one-to-one relationship with the intervener.”

Implementation of Antiretroviral Therapy Adherence Interventions: A Realist Synthesis of EvidenceJ Adv Nurs. 2010 Sep; 66(9): 1915–1930.

Suresh

Improving retention

No “one size fits all”

Measure our retention rates

Defaulter tracing

Alternative methods of delivering care

Differentiated care

After office hours

Tele clinic

Individualised care for those who need

Community participation

Suresh

Thank youHospital Sungai Buloh

“Seek, Test, Treat & Retain”