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Background

HIV clinical and program outcomes among older patients with HIV enrolled in HIV care and initiating ART in sub-Saharan Africa.

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Background

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  1. HIV clinical and program outcomes among older patients with HIV enrolled in HIV care and initiating ART in sub-Saharan Africa Matthew R. Lamb1,2, Eduard Eduardo1,2, Sasi Kandula1, Andrea Howard1,2, Veronica Mugisha1, Davies Kimanga3, Bonita Kilama4, Wafaa El-Sadr1,2, BatyaElul1,2 For the Optimal Models of HIV Care and Treatment in sub-Saharan Africa consortium 1ICAP at Columbia University 2Department of Epidemiology, Mailman School of Public Health, Columbia University 3National AIDS and STI Control Programme, Nairobi, Kenya 4National AIDS Control Programme, Dar es Salaam, Tanzania

  2. Background • Antiretroviral treatment (ART) success results in more HIV-infected individuals living longer and growing older • HIV-infected older adults (> 50 years of age) have higher mortality, more co-morbidities (noted in studies from resource-rich settings) • Resource-limited settings: little reported information focusing on HIV+ adults >50 years

  3. Study objectives • To compare HIV+ adults >50 years to those • 15-49 years enrolling in HIV clinics in sub-Saharan Africa with respect to: • Gender distribution • Median CD4+ count at enrollment and ART initiation • Mortality and loss to follow-up one year after enrollment and ART initiation • CD4 response after ART initiation

  4. Study population and setting • 199 HIV clinics in Kenya, Mozambique, Rwanda, and Tanzania • Supported by ICAP-Columbia University in partnership with health ministries • Funded through PEPFAR • Adults >15 years • Enrolling into HIV care between Jan 2005-Dec 2010

  5. Data sources • Clinical data recorded on national forms as part of routine care, then entered into electronic patient-level databases • Data quality assessed at least annually • Each quarter, databases are de-identified and combined across countries • Approved under PEPFAR-supported public health evaluation “Identifying Optimal Models of HIV Care” (CDC PHE 07.0117)

  6. Statistical Methods • Compared adults >50 years vs.15-49 years with respect to: • Gender distribution & median CD4 count at enrollment & ART initiation using descriptive statistics • Incidence of reported death & loss to follow-up one year after enrollment and ART initiation: • Kaplan-Meier and log rank tests • Cox Proportional Hazards models, adjusting for clinic- and patient-level characteristics • Change in CD4+ count after ART initiation: • 79,087 (44%) of patients had required data • Time-dependent linear regression, adjusting for clinic- and patient-level characteristics

  7. Results

  8. Population distribution 80% of adults >50 years of age are between 50 and 60 years old

  9. Proportion of adults >50 years attending HIV clinics has increased over time 10.0% p = 0.33

  10. Proportion of adults >50 years attending HIV clinics has increased over time 14.4% p < .0001 10.0% p = 0.33

  11. Proportion of adults >50 years attending HIV clinics has increased over time 14.4% p < .0001 12.0% p < .0001 p = 0.33 10.0%

  12. Proportion of adults >50 years attending HIV clinics has increased over time p < .0001 15.8% 14.4% p < .0001 12.0% p < .0001 10.0% p = 0.33

  13. Adults >50 years of age more likely to be male p < .0001

  14. Patients >50 years have lower CD4 counts at HIV care enrollment, similar CD4 at ART initiation > 50 yrs 15-49 yrs Enrollment ART initiation p<0.001 p<0.001

  15. Reported mortality is higher among adults > 50 years… Proportion surviving >50 yrs, since enrollment 15-49 yrs, since enrollment Log-rank test: p < .0001 >50 yrs, since ART initiation 15-49 yrs, since ART initiation Time (yrs) since enrollment (solid)/ ART initiation (dotted)

  16. ..while loss to follow-up lower among adults > 50 years Proportion remaining in care Log-rank test: p < .0001 Time (yrs) since enrollment (solid)/ ART initiation (dotted)

  17. Increased mortality, decreased LTF among adults > 50 years remains after multivariate adjustment Death LTF 0.83 (0.80-0.86) 0.80 (0.76-0.85) Hazard Ratio and 95% CI: >50 years vs. 15-49 years 1 year after ART initiation 1.26 (1.18-1.34) Crude Crude Adjusted Adjusting for: country, facility type (10, 20, 30), location (urban, semi-urban, rural), CD4 at ART initiation, sex, and year of ART initiation

  18. Adults >50 years had lower CD4+ count response after ART initiation Women All Patients Men > 50 years 15-49 years

  19. CD4+ count response after ART initiation: > 50 years vs. 15-49 years Relative one-year increase in CD4 (cells/mm3) Averageone-year increase in CD4 (cells/mm3) 130 Reference -15.9 114.1 -4.6 to -27.1 Adjusting for: country, facility type (10, 20, 30), location (urban, semi-urban, rural), CD4 at ART initiation, timing of post-initiation CD4 measure(s), sex, and year of ART initiation

  20. Conclusions • Proportion of active patients >50 years of age increased steadily over time • Compared to younger adults, substantially higher proportion of adults >50 years of age are male • Adults >50 years had better retention, but inferior CD4+ count response and higher mortality after ART initiation • Additional research needed in the older population: • Reduced CD4+ count response after ART initiation • Reasons for higher mortality and role of co-morbidities • Comparison of mortality with background mortality

  21. Acknowledgements • Ministries of Health in Kenya, Mozambique, Rwanda, Tanzania • CDC in-country staff in Kenya, Mozambique, Rwanda, Tanzania • President’s Emergency Plan for AIDS Relief • Staff at ICAP-supported sites • ICAP country and NY staff, especially Elaine Abrams • People living with HIV

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