www.khethimpilo.org

Reaching 90-90-90 in South Africa Part III: Best Practices and Innovations in Linkage, Treatment and Viral Suppression. Pretoria

31 May 2016

Geoffrey Fatti

The antiretroviral treatment (ART) program in SA has

expanded rapidly and now includes > 3 million people on

ART.

However, long-term patient retention in public programs is

challenging, with patient retention of 58% nationally after

4 years of ART.*

Viral resistance and treatment failure rates are increasing.

To attempt to improve ART adherence, viral suppression

and long-term patient retention, a community-based

adherence support program was introduced by

Kheth’Impilo since 2004.

Kheth’Impilo is an NPO that supports DOH with public

health systems innovations.* Patients starting ART in 2008/09. NDoH ART program analysis 2004-2014

• Community health workers provide adherence and psychosocial

support for ART patients.

• Perform home visits & assess patients and household to identify

potential issues that adversely affect adherence: eg. non-disclosure,

substance abuse, nutrition security, domestic violence etc.

• Patients encouraged to adhere to positive lifestyle choices that include

taking treatment & keeping clinic appointments.

• Plan support to suit individual client needs through planned home

visits and clinic-based support.

Special attention paid to those ill, pregnant women, with TB, children,

those with irregular clinic attendance.

AIM: To evaluate the effectiveness of community adherence

support for patients receiving ART in routine settings in SA.

A multicentre cohort study was performed at 77 facilities in four

provinces.

Included adults, adolescents and children starting ART since

2004.

Prospectively collected routine clinical data were analysed.

Outcome measures: mortality, loss to follow-up, viral suppression

and CD4 cell increases after starting ART.

Outcomes compared between patients who received and did not

receive CBAS.

Results

71,806 patients included, 20,650 (28.8%) received CBAS and 51,156

(71.2%) did not.

Observation time: 105,143 person-years

Geoffrey Fatti, Graeme Meintjes, Jawaya Shea, Brian Eley, Ashraf Grimwood. Improved Survival and Antiretroviral Treatment Outcomes in Adults Receiving Community-Based Adherence Support: Five-Year Results from a Multicentre Cohort Study in South Africa.

Journal of Acquired Immune Deficiency Syndromes. 2012; 61(4): e50-e58

0.00

0.05

0.10

0.15

0.20

Cum

ula

tive in

cid

en

ce o

f lo

ss to

follo

w-u

p

0 12 24 36 48 60

Months since starting ART

35% reduction in mortality; aHR 0.65 [95% CI: 0.59-72]

37% reduction in loss to follow-up; aHR0.63 [95% CI: 0.59-0.68]

Without CBAS

With CBAS

Ashraf Grimwood, Geoffrey Fatti, Mokgadi Malahlela, Jawaya Shea, Brian Eley. Community Adherence Support Improves Program Retention in Children on

Antiretroviral Treatment: a Multicentre Cohort Study in South Africa. Journal of the International AIDS Society. 2012; 15(2): 1-9

43% reduced hazard of attrition: aHR 0.57 (CI: 0.35–0.94)

60% reduction in mortality with CBAS: aHR0.40 (CI: 0.15–1.06)

0.7

0.8

0.9

1.0

Pro

ba

bility o

f re

main

ing

in c

are

0 12 24 36

Months since starting ART

0.00

0.02

0.04

0.06

0.08

Pro

ba

bility o

f d

ea

th

0 12 24 36

Months since starting ART

Without CBAS

With CBAS

With CBAS

Without CBAS

Geoffrey Fatti, Najma Shaikh, Brian Eley, Ashraf Grimwood. Improved VirologicalSuppression in Children on Antiretroviral Treatment Receiving Community-based

Adherence Support: A Multicentre Cohort Study from South Africa. AIDS Care 2014; 26(4): 448-53

50% improvement: aOR: 1.49 (95% CI: 1.40-1.58

60% improvement: aOR 1.60 (95% CI: 1.35-1.89)

Geoffrey Fatti, Eula Mothibi, Najma Shaikh, Ashraf Grimwood. Improved Long-Term Antiretroviral Treatment Outcomes Amongst Patients Receiving Community-Based

Adherence Support in South Africa. AIDS Care, 2016. In press.

asHR 0.74 (95% CI: 0.66-0.84) aRR: 0.47 (95% CI: 0.26-0.86)

11.4%

19.4%

0%

5%

10%

15%

20%

With CBAS Without CBAS

% p

ati

en

ts w

ith

un

su

pp

ressed

vir

al

load

with CBAS

without CBAS

P<0.0001

0

.1

.2

.3

.4

.5

Cu

mu

lative

in

cid

en

ce

of lo

ss to

fo

llo

w u

p

0 1 2 3 4 5 6 7 8Years after starting ART

100

150

200

250

300

350

400

450

CD

4 ce

ll co

unt i

ncre

ase

from

bas

elin

e

0 1 2 3 4 5 6 7 8

Years since starting ART

without CBAS

with CBAS

0

50

100

150

200

250

300

350

CD

4 c

ell

cou

nt in

cre

ase

fro

m 6

mo

nth

s o

f A

RT

0 1 2 3 4 5 6 7 8

Years since starting ART

without CBAS

with CBAS

Adjusted annual CD4 cell slope between 6.5- 8 years

of ART:

19.1 cells/µL/year (95% CI: 3.5-34.8) greater amongst CBAS patients (P=0.016)

P=0.0053

0.00

0.25

0.50

0.75

1.00

Pro

ba

bility o

f A

RT

in

itia

tio

n

0 30 60 90 120 150 180Days after first antenatal visit

without community-based support

with community-based support

Geoffrey Fatti, Najma Shaikh, Brian Eley, Ashraf Grimwood. Effectiveness of community-based support for pregnant women living with HIV: a cohort study in South Africa. AIDS

Care . 2016, Feb (epub ahead of print)

ART patients who received community-based adherence

support had reduced mortality, reduced LTFU, improved

viral suppression, improved immune restitution after

starting ART. Improved ART initiation in pregnant women.

Low-cost intervention (~ R15 - R30 /patient /month) that

can be introduced and developed in resource-poor

settings. Cost-effectiveness analyses currently being

conducted.

Community adherence support is important for ensuring

good ART outcomes & should be closely linked and

coordinated with primary level healthcare services.

“This presentation was made possible by the Presidents Emergency Plan for AIDS Relief (PEPFAR) through the United States Agency for International Development (USAID). The content of the presentation are the sole responsibility of Kheth’Impilo and do not necessarily represent the official views of USAID or the United States Government.”