Launch of the JIAS supplement 27 October 2021 webinar Differentiated service delivery for people on secondline antiretroviral therapy Evidence from KwaZuluNatal South Africa Lewis L Sookrajh Y Gate K Khubone T Maraj M Mkhize S Hermans LE Ngobese H Garrett N Dorward J ID: 936022
Download Presentation The PPT/PDF document "Differentiated service delivery for HIV ..." is the property of its rightful owner. Permission is granted to download and print the materials on this web site for personal, non-commercial use only, and to display it on your personal computer provided you do not modify the materials and that you retain all copyright notices contained in the materials. By downloading content from our website, you accept the terms of this agreement.
Slide1
Differentiated service delivery for HIV during COVID-19: Lessons and opportunitiesLaunch of the JIAS supplement
27 October 2021 webinar
Slide2Differentiated service delivery for people on second-line antiretroviral therapy: Evidence from KwaZulu-Natal, South Africa
Lewis L, Sookrajh Y, Gate K, Khubone T, Maraj M, Mkhize S, Hermans LE, Ngobese H, Garrett N, Dorward J
§
§Jienchi DorwardClinical Research Fellow in Primary Healthcare, University of Oxford, UKHonorary Associate Scientist, CAPRISA, Durban, South Africajienchi.dorward@phc.ox.ac.uk
Slide3Background
People living with HIV who are receiving second-line antiretroviral therapy (ART) have not always been included in differentiated service delivery (DSD)
programmes
, and there is little data evaluating their outcomes. South Africa implemented a community-based differentiated ART delivery programme in 2016, which included people receiving second-line ART and with viral suppressionWe aimed to assess treatment outcomes among people on second-line ART in a community delivery programme, compared to those who remained at clinics
Nurses working in a South African community ART delivery program
Slide4MethodologyRetrospective cohort study of people receiving second-line ART and eligible* for community ART delivery, between October 2016 and December 2018
Routinely collected data from 61 primary care clinics in South Africa
Multivariable logistic regression models to compare attrition and viraemia at 12 months among those referred for community ART versus those who remained in clinic care
Figure 1: Map of clinic areas
KwaZulu-Natal
*Two suppressed viral loads
>
6 months apart, stable on ART regimen for
>
12 months, clinically stable
Slide5Results2,575 people on second-line ART and potentially eligible for community ART deliveryMedian age 39.0 years (IQR 34.0-45.0), 1,670 (64.9%) were women. 584 (22.7%) were referred for community ART within 6 months of meeting eligibility criteria
Participant flowchart
Slide6Referred to community ART programme
(n=584)
Continued at clinic (n=1,991)
Baseline characteristics
Age, median (IQR)
39(35-45)
39(34-45)
Gender, n(%)
Female
384(65.8)
1286(64.6)
District, n(%)
Urban
540(92.5)
1849(92.9)
Year of baseline observation, n(%)
2016
30(5.1)
310(15.6)
2017309(52.9)977(49.1) 2018245(42.0)704(35.4) Second-line protease inhibitorLopinavir/ritonavir581(99.5)1980(99.5) Atazanavir3(0.5)11(0.5) NRTI backbone†Tenofovir165(28.2)514(25.8) Zidovudine377(64.6)1315(66.1) Abacavir/Other‡42(7.2)162(8.1) Months on second-line ART, median (IQR)28.5(18-50)26(16-45) Months since viral load measure preceding baseline viral load, median (IQR) 11(8-13)11(8-13) Most recent CD4 count at baseline, median (IQR) 449(260-622)385(237-555) Most recent CD4 count at baseline, n(%)<=20034(11.3)176(15.8) 201-35070(23.2)277(24.9) 351-50055(18.3)272(24.4) >500142(47.2)389(34.9) Missing283877 Months since most recent CD4 count at baseline, median (IQR) 9(0-15)9(0-15)Follow-up characteristics Months to viral load follow-up measurement, median (IQR)12(11-12)12(11-12) Missing viral load follow-up value, n(%) 87(14.9)350(17.6)
†Tenofovir typically combined with emtricitabine, zidovudine and abacavir typically combined with lamivudine ‡All but 2 clients were on Abacavir
Baseline & follow-up characteristics
, split by referral for community ART (n=2,575)
Slide7ResultsIn this cohort of people established on second-line and eligible for community ART delivery:
Attrition at 12 months was very low
4.5% (95% CI 3.0-6.6%) in the community ART arm
4.4% (95% CI 3.5-5.4%) in the clinic care armViraemia at 12 months was low10.3% (95% CI 7.7-13.3%) in the community ART arm11.3% (95% CI 9.8-12.9%) in the clinic care arm
Slide8No recorded visit 12-18 months after baseline, n(%) or median (IQR)
OR (95% CI)
Adjusted OR (95% CI)
Age at baseline
39.5 (33-45)
1.00(0.98-1.02)
1.01(0.99-1.03)
Gender
Female
75 (4.7)
1.15(0.83-1.6)
1.21(0.87-1.67)
Male
35 (4.0)
1
1
District
Rural
6 (3.4)
0.71(0.35-1.45)0.75(0.35-1.62) Urban104 (4.5) 11Year of baseline observation201614 (4.2) 0.86(0.56-1.34)0.87(0.55-1.39)201752 (4.1) 0.83(0.55-1.25)0.84(0.55-1.27) 201844 (4.9) 11NRTI backbone at baselineTenofovir28 (4.2) 1.00(0.63-1.58)1.05(0.64-1.72)Abacavir/Other14 (7.0) 1.71(0.94-3.11)1.7(0.94-3.1) Zidovudine68 (4.2) 11Months on 2nd line at baseline 25 (14-46) 1.00(0.99-1.004)1.00(0.99-1.005)Referred for community ARTYes26 (4.5) 1.01(0.71-1.45)1.02(0.71-1.47) No84 (4.4) 11Multivariable logistic regression model of attrition, n=2,496No difference in attrition among those on second-line regimens referred to community ART compared to those remaining in clinic care (aOR 1.02, 95% CI 0.71-1.47) Attrition
Slide9Multivariable logistic regression model of
viraemia
(>200 cps/ml), n=2,138
Viral load
>
200, n(%) or median(IQR)
OR (95% CI)
Adjusted OR (95% CI)
Age at baseline
39 (33-44)
0.99(0.97-1)
0.99(0.97-1.01)
Gender
Female
151 (10.8)
0.94(0.7-1.27)
1.03(0.74-1.45)
Male
85 (11.6)
1
1DistrictRural11 (7.1) 0.63(0.51-0.78)0.83(0.65-1.05) Urban225 (11.3) 11Year of baseline observation201626 (8.9) 0.67(0.42-1.06)0.66(0.38-1.13)2017114 (10.6) 0.83(0.62-1.1)0.86(0.64-1.16) 201896 (12.5) 11NRTI backbone at baselineTenofovir45 (7.9) 0.67(0.48-0.92)0.78(0.55-1.11)Abacavir/ Other29 (17.3) 1.7(1.16-2.5)1.78(1.21-2.63) Zidovudine162 (11.6) 11Months on 2nd line at baseline 22 (16-36.5) 0.99(0.99-1)1.00(0.99-1.00)Referred for community ARTYes51 (10.3) 0.89(0.64-1.24)0.91(0.64-1.29) No185 (11.3) 11No difference in viraemia among those on second-line regimens referred to community ART compared to those remaining in clinic care (aOR 0.91, 95% CI 0.64-1.29) Viraemia
Slide10Sensitivity analysesAdjusting for CD4 count in multi-variable model
No difference in 12 month attrition
(n=1366, aOR 1.17, 95% CI 0.77–1.77)
No difference in 12 month viraemia (n=1143, aOR 1.21, 95% CI 0.75–1.94)Including clients who were transferred out to another clinicAttrition was lower in the community ART group versus clinic care (n=2575, aOR 0.73, 95% CI 0.54–0.99
Slide11DiscussionOne of the largest and first analyses to assess outcomes among people on second-line ART in a differentiated community ART delivery programmeHigh retention and viral suppression in this population
However, people referred for community ART may be selected because they are likely to have better outcomes
Findings are from pre-COVID-19, and South African DSD eligibility criteria are now less strict
Slide12Next steps
Programmes which do not already include second line treatments in differentiated ART delivery services should
consider
introducing them for people with viral suppression2021 revised WHO guidelines definition of “established on treatment“ inclusive of those on second- and third-line regimensLonger term outcome data beyond 12 months, and during the COVID-19 pandemic, need to be assessed
Slide13AcknowledgementsCollaborators
eThekwini Municipality Health Unit
CAPRISA
University of OxfordFundersInternational AIDS Society Fast Track CitiesWellcome Trust