CROI 2016 Abstract eBook

Abstract Listing

Poster Abstracts

1019 Identifying Hotspots of Poor Adherence Among Patients on ART in Zambia Nancy L. Czaicki 1 ; Charles Holmes 2 ; Izukanji Sikazwe 2 ; Paul Somwe 2 ; Monika Roy 3 ;Thea Savory 2 ; Mwanza Mwanza 2 ; DavidV. Glidden 3 ; Nancy Padian 1 ; Elvin H. Geng 3 1 Univ of California Berkeley, Berkeley, CA, USA; 2 Cntr for Infectious Disease Rsr in Zambia, Lusaka, Zambia; 3 Univ of California San Francisco, San Francisco, CA, USA Background: The distribution of poor adherence to antiretroviral therapy (ART) in a patient population indicates whether barriers to medication use are concentrated within sub-populations or systematic. We quantify the medication possession ratio (MPR) and characterize the distribution of medication non-possession in a network of clinics in Zambia to identify “hotspots” of poor adherence. Methods: We analyzed a population of adults on ART for more than 3 months who made at least one clinic visit between March 1, 2013 and February 28, 2015. Pharmacy refill and clinical information were obtained through the electronic medical record system used in routine care. MPR was calculated as the number of days of ART dispensed over the total number of days the patient should have been on ART using pharmacy records. We constructed a Lorenz curve, plotting the cumulative proportion of days of medication non-possession against the cumulative proportion of patients to visualize the distribution of poor adherence. We used a multi-level linear regression model to examine clinic and individual-level factors associated with MPR. Results: Among 133,827 patients in 56 clinics (64% female, median age 34 years [IQR 29-41], median baseline CD4 count 208 cells/µl [IQR 111-333]), the median MPR was 80.7 [IQR 64.4-91.4] indicating patients were not in possession of ART 19.3% of the time. After 1 year on ART, 31% of patients had 100%medication possession, the next 57% account for 50% of medication non-possession and the final 12% contribute the remaining 50%. Over time, a greater proportion of patients contribute to days of non-possession (Figure). In multi-level regression, disclosure of HIV status (3.3%, p<0.001) and ART initiation 2012-2015 (16.2%, p<0.001) were associated with higher MPR, while enrollment WHO Stage 4 (-2.58%, p <0.001) and male (-1.16%, p<0.001) were linked to lower MPR. Across clinics, median MPR ranged from 43.2 to 94.7 and clinic accounted for 16% of the total variability in MPR after adjusting for individual and clinic-level characteristics. Conclusions: A small fraction of patients account for the majority of days of medication non-possession, especially early on. Further characterization of these patient sub- populations where non-adherence is concentrated is needed to target individual-level interventions. Clinic, however, explained the greatest amount of variability in MPR. Health systems interventions targeting clinic “hot spots” may represent an efficient use of resources to improve ART adherence.

Poster Abstracts

1020 Late ART Initiation and 12-Month Mortality After ART Initiation in Sub-Saharan Africa Quynh T. Vo 1 ; OlgaTymejczyk 2 ; Batya Elul 3 ;Wafaa M. El-Sadr 4 ;YingfengWu 4 ; Laurence Ahoua 5 ; Sarah Kulkarni 6 ; Susie Hoffman 3 ; Denis Nash 2 1 ICAP at Columbia Univ, Boston, MA, USA; 2 Sch of PH, City Univ of New York, New York, NY, USA; 3 Columbia Univ, New York, NY, USA; 4 ICAP at Columbia Univ, New York, NY, USA; 5 ICAP at Columbia Univ, Maputo, Mozambique; 6 City Univ of New York, New York, NY, USA Background: The effect of late antiretroviral therapy (ART) initiation and changing ART guidelines on patient outcomes has not been fully characterized due to under- ascertainment of mortality. We examined changes in mortality rates before and after the adoption of WHO 2010 treatment guidelines after accounting for unascertained deaths. Methods: Kaplan-Meier 12-month mortality estimates were calculated for 113,118 patients who had initiated ART at 83 clinics between 2005-2013 in Tanzania (n=26), Mozambique (n=23), and Kenya (n=34). We examined corrected 12-month mortality estimates that reflect unascertained deaths using a correction factor from patient tracing studies in the region. Changes in mortality rates (percent per year) by country both before and after adoption of WHO 2010 treatment guidelines (from CD4≤200 to ≤350) were estimated using a linear regression model. We calculated relative risks (RR) of late ART initiation (CD4≤100 or WHO stage 4) and mortality at 12 months following ART initiation by 2012vs.2010 :0.92, 95% CI:0.82-1.04, p=0.21). Over the period prior to the guideline change (secular trend), the corrected mortality rates declined by 1.2% per year in Tanzania (95% CI 1.2-2.2, p<0.05), 4.2% per year in Mozambique (95% CI 3.6-4.7, p<0.0001) and 6.2% per year in Kenya (95% CI 5.3-7.1, p<0.0001). The corrected mortality estimates showed a significantly reduced risk of deaths after versus before guideline change in Tanzania (RR 2012vs.2010 :0.65, 95% CI:0.58-0.71, p<.0001), Mozambique (RR 2013vs.2011 :0.42, 95% CI:0.39-0.46, p<.0001) and Kenya (RR 2012vs.2010 :0.83, 95% CI:0.73-0.96, p<.05). These changes exceeded secular trends in all three countries, but to a lesser extent in Kenya (Figure 1). comparing these outcomes during the year before and the year after guideline changes. Results: Late ART initiation significantly decreased after guideline changes in Tanzania (RR 2012vs.2010 :0.91, 95% CI:0.86-0.97, p<.05), and Mozambique (RR 2013vs.2011 : 0.69, 95% CI:0.65-0.73, p<.0001) but not in Kenya (RR

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CROI 2016