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Early survival and clinic retention among high risk HIV-infected patients initiating combination antiretroviral treatment (cART) in a pilot express care system compared to routine care in Western Kenya
Presented by Paula Braitstein, United States.
P. Braitstein1, A. Siika2, R. Kosgei3, E. Sang3, J. Sidle1, K. Wools-Kaloustian1, C. Yiannoutsos1, W. Tierney1, J. Mamlin1, S. Kimaiyo2
1Indiana University, School of Medicine, Indianapolis, United States, 2Moi University, School of Medicine, Eldoret, Kenya, 3USAID-Academic Model for the Prevention and Treatment of HIV/AIDS (AMPATH) Partnership, Eldoret, Kenya
Background: The USAID-AMPATH partnership has enrolled >65,000 patients at 18 clinics in western Kenya. In 03/07, Express Care (EC) was implemented for patients initiating cART considered at high risk of mortality and loss to follow-up (LTFU) in 12 clinics.
Methods: EC provides weekly visits by nurses for three months to patients starting cART with a CD4 £100. Sick patients are immediately referred to clinicians. Routine Care (RC) patients receive monthly clinician assessments and refills. We compared survival and retention among previously ART-naïve patients ³14 years with CD4£100, initiating cART. Death was ascertained by aggressive outreach; LTFU was defined as no clinic visits for >3 months. We calculated incidence rates (IR), IR ratios (IRR), and 95% confidence intervals (CI) per 100 person-months (PM) of follow-up, and modelled the adjusted effect of EC with Cox regression.
Results: Since 03/07, 2594 eligible patients initiated cART; 378 (14.6%) were in EC. Both groups were 60% female, median age 37 years; median CD4 at ART initiation in EC was 47 cells/mm3 vs. 44 in RC (p=0.620); 35% in both groups received tuberculosis treatment at ART initiation. In EC, 68% vs. 46% in RC attended urban clinics (p<0.001). There were 348 events (death or LTFU: DLTF) in 11,463.5 person-months of follow-up, including 32 (8.5%) in EC, and 316 (14.3%) in RC. The incidence of DLTF was 1.6/100PM in EC vs. 3.2 in RC. The IRR in favour of EC was 0.48 (0.32-0.69), p<0.001. In Cox regression adjusting for CD4 count closest to ART initiation, gender, and clinic location, being in EC was associated with a reduced risk of DLTF (Adjusted Hazard Ratio, 95%CI) of 0.54 (0.37-0.77, p=0.001).
Conclusions: Frequent monitoring by dedicated nurses in the early months of ART decreases mortality and LTFU by 50% among high-risk patients. This intervention could be widely implemented in developing countries.
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