Test and Keep in Care Poor linkage to care despite significant improvement in access to early cart data from Test and Keep in Care (TAK) project. Leah Shepherd, Magdalena Ankiersztejn-Bartczak, Aneta Cybula, Hanna Czeszko-Paprocka, Ewa Firląg-Burkacka, Andrzej Horban, Amanda Mocroft and Justyna D. Kowalska Hospital for Infectious Diseases, HIV Out-Patients Clinic, Warsaw, Poland, Medical University of Warsaw, Department for Adults' Infectious Diseases, Warsaw, Poland
So where we are? Unemployment Avarage salary Migration (saldo)
Background Up to 50% of HIV-infected persons in Europe remain undiagnosed Half of newly diagnosed HIV patients are late presenters Increased HIV testing and improving care pathway are strongly encouraged Only persons linked to care can fully benefit from being diagnosed It is unknown how many diagnosed patients remain outside care Antinori A. Antivir Ther 2010, Mocroft A. PLoS 2013, Wynberg E JIAS 2014
Test and Keep in Care (TAK) project Prospective follow-up of HIV persons diagnosed in CBVTC in central Poland Data collection: pre-clinical from CBVTC questionnaire and visits clinical from HIV clinics Main end-point: linkage to care Study aims: estimate the prevalence of HIV-positive persons lost or late to care investigate related factors in order to target effective interventions for linkage to care Ankiersztejn-Bartczak M. HIV Med. 2015
Methods data from CBVTC (2010-2013) and HIV clinics were linked using unique Western-Blot number persons tested at CBVTC and registered in HIV clinics databases were linked to care latest follow up date was 4/06/2014
HIV clinic Anonymoust testing at CBVTC From CBVTC to HIV clinic Counselling ELISA + result not collected by CBVTC client Lost to care WB+ result not collected by CBVTC client Lost to care Decoding not agree Lost to care Clinic not regisdtered Lost to care Linked to care
Methods - Statistical analyses Cox-proportional hazard models were used to identify factors associated with: being linked to care (LTC) baseline date of HIV test starting cart baseline date of first visit to HIV clinic Both pre-clinical (16) and clinical factors were included into analyses and tested as potential predoctors of linkage to care
Results linked to care 232 persons tested HIV+ in CBVTC 144 (62.1%) were linked to care (95%CI:60%-70%) 81.2% registered within 3 months from testing Medial follow-up per person 3 months (95%CI:1-23) 239 person years of follow-up * As provided in CBVTC questionnaire
Baseline characteristics for those who were tested Median (IQR) Total n (%) Not linked to care Linked to care P value Total number 232 ( 100) 88 ( 100) 144 ( 100) - Age at test <=30* 116 (50.0) 50 (56.8) 66 (45.8) 0.105 Male sex 220 (94.8) 83 (94.3) 137 (95.1) 0.784 Polish nationality 223 (96.1) 83 (94.3) 140 (97.2) 0.276 High education 180 (77.6) 63 (71.6) 117 (81.3) 0.089 MSM 175 (75.4) 55 (62.5) 120 (83.3) <.001 Test at CBVCT 128 (55.2) 44 (50.0) 84 (58.3) 0.216 No test last year 65 (28.0) 25 (28.4) 40 (27.8) 0.917 Year of test 2010 32 (13.8) 14 (15.9) 18 (12.5) 0.575 2011 76 (32.8) 31 (35.2) 45 (31.3) 2012 70 (30.2) 22 (25.0) 48 (33.3) 2013 54 (23.3) 21 (23.9) 33 (22.9) * median age 30.1 (IQR: 25.2-35.9) years
Baseline characteristics for those who were tested Median (IQR) Total n (%) Not linked to care Linked to care P value STI 35 (15.1) 11 (12.5) 24 (16.7) 0.391 Partner tested 84 (36.2) 32 (36.4) 52 (36.1) 0.969 Partner HIV+ 53 (22.8) 13 (14.8) 40 (27.8) 0.024 Stable relationship within last year 27 (11.6) 15 (17.0) 12 ( 8.3) 0.049 Condom use with stable partners 100 (43.1) 30 (34.1) 70 (48.6) 0.031 Condom use with casual partners 132 (56.9) 47 (53.4) 85 (59.0) 0.402 No of stable partners 1-5, unknown 67 (28.9) 29 (33.0) 38 (26.4) 0.549 6-20 93 (40.1) 34 (38.6) 59 (41.0) >21 72 (31.0) 25 (28.4) 47 (32.6) No of casual partners 1-5, unknown 176 (75.9) 69 (78.4) 107 (74.3) 0.495 6-20 40 (17.2) 12 (13.6) 28 (19.4) >21 16 ( 6.9) 7 ( 8.0) 9 ( 6.3)
Kaplan-Meier plots
Variable Age at test (per year older) Linked to care Unadjusted hazard ratios and 95% CI Education lower /unknown Bi/heterosexual orienation Partner not HIV+ * Not in stable relationship last year* No condom use with stable partners* * or unknown 0.25 0.5 1 2 4 worse linkage HR (95%CI) better linkage Only variables significant in univariate analyses (p <0.1) are shown above Unadjusted model Adjusted model
Linked to care Unadjusted and adjusted hazard ratios and 95% CI Variable Age at test (per year older) Education lower /unknown Bi/heterosexual orienation Partner not HIV+ * Not in stable relationship last year* No condom use with stable partners* * or unknown 0.25 0.5 1 2 4 worse linkage HR (95%CI) better linkage Multivariate models adjusted for variables significant in univariate analyses (p <0.1) as shown above Unadjusted model Adjusted model
Results starting cart 116 (80.5%) started cart during follow up CD4 count was 393 (292-506) cells/ul * HIV RNA was 4.5 (3.9-5.1) log copies/ml* Median follow-up per person 3 (95% CI:1-16) months 118 person years of follow-up Pre-clinical characteristics were similar for patients who started and not started cart * Median (IQR) of baseline measurement at first clinic visit
Clinical characteristics for those who were linked and started cart Median (IQR) anti-hbc at first visit Total n(%) Not started cart Started cart P value Yes 16 (11.1) 5 (18.5) 11 ( 9.4) 0.40 No 103 (71.5) 18 (66.7) 85 (72.6) Unknown/missing 25 (17.4) 4 (14.8) 21 (17.9) anti- HCV at first visit Yes 3 ( 2.1) 0 ( 0.0) 3 ( 2.6) 0.78 No 125 (86.8) 25 (92.6) 100 (85.5) Unknown/missing 16 (11.1) 2 ( 7.4) 14 (12.0) Syphilis at first visit Yes 30 (20.8) 7 (25.9) 23 (19.7) 0.47 No/undetermined 100 (69.4) 19 (70.4) 81 (69.2) Unknown/missing 14 ( 9.7) 1 ( 3.7) 13 (11.1) HIV RNA at baseline 0-10,000 40 (27.8) 16 (59.3) 24 (20.5) <.001 <10,000 104 (72.2) 11 (40.7) 93 (79.5) CD4 at baseline 1-350 49 (34.0) 2 ( 7.4) 47 (40.2) 0.005 351-500 58 (40.3) 12 (44.4) 46 (39.3) > 500 37 (25.7) 13 (48.1) 24 (20.5)
Kaplan-Meier plots
Kaplan-Meier plots 50% 60% 90%
Variable Age at test (per year older) Started cart Unadjusted hazard ratios and 95% CI Education lower /unknown Year of linked to care 2012 vs. 2010/11 2013/14 vs. 2010/11 No STI/unknown No condom use with casual partners* Number of casual partners 6-20 vs 1-5 >21 vs 1-5 HIV RNA (/10 fold higher) CD4 (/2 fold higher) Only variables significant in univariate analyses (p <0.1) are shown * or unknown 0.125 0.25 0.5 1 2 4 8 delaying cart HR (95%CI) starting cart Unadjusted model Adjusted model
Variable Age at test (per year older) Education lower /unknown Year of linked to care 2012 vs. 2010/11 2013/14 vs. 2010/11 No STI/unknown No condom use with casual partners* Number of casual partners 6-20 vs 1-5 >21 vs 1-5 HIV RNA (/10 fold higher) CD4 (/2 fold higher) Started cart Unadjusted and adjusted hazard ratios and 95% CI * or unknown 0.125 0.25 0.5 1 2 4 8 delaying cart HR (95%CI) starting cart Unadjusted model Adjusted model
Limitations patients classified as lost to care could migrated to or registered at non-regional clinics Rather trend towards centralisation of migration for care it is not possible to perform external quality assurance to exclude double testing in Polish settings (anonymous registration) patients re-test mostly due to undetermined WB result
Conclusions Benefits of HIV care, measured by access to early treatment, steadily improved in recent 4 years 1 in 3 persons aware of their HIV status remain outside professional healthcare Bi/heterosexual persons with primary/unknown education are at higher risk of remaining outside care despite being diagnosed
Perspectives All CBVTC in Poland record Western blot test numbers as a possible cross-check Next TAK step is introducing targeted intervention in 2015
Acknowledgments unrestricted research grant received from : data from testing facilities were provided by National AIDS Centre (Krajowe Centrum AIDS) and Foundation of Social Education
To all people who continuously support us. Thank you