THE SUCCESSES OF AND BARRIERS TO REACHING AMBITIOUS HIV TREATMENT TARGETS IN RAKAI, UGANDA
Billioux, Veena G.
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Objective: The HIV treatment cascade, also referred to as the HIV care continuum, is comprised of the sequential stages of engagement in HIV medical care, from testing to diagnosis to achieving the goal of viral suppression, measured as the proportion of individuals living with HIV who are engaged at each stage. We used clinical data as well as data from the population-based Rakai Community Cohort Study (RCCS), an open HIV surveillance cohort, to characterize the HIV treatment cascade, assess the association between sexual risk behaviors and initiation of antiretroviral therapy (ART), and to explore geospatial patterns of ART treatment facility use and viral suppression, in Rakai District, Uganda. Methods: Self-reports from the RCCS and clinical records, both collected between 2013-2016, were used to assess the proportions of HIV-positive persons in the cohort achieving each stage in the cascade (n=3,666). Next, we examined HIV risk factors based on sexual behaviors reported for the 12 months prior to the interview, including number of sex partners, non-marital sex partners, sex with partners from outside the community of residence, alcohol use before sex, consistent condom use with non-marital partners, and symptoms of genital ulcer disease. Statistical inference was based on χ2 tests for categorical variables and modified Poisson regression to estimate prevalence risk ratios (PRRs) and 95% confidence intervals (95%CIs) of enrollment into HIV care and ART use associated with each HIV risk factor, for the whole population and stratified by sex. To explore the geospatial and demographic factors associated with accessing treatment services, we extracted data on the location and type of care services utilized by HIV-positive persons (n = 1670) accessing treatment between February 2015 and September 2016. The distance to facilities offering HIV care in the region was calculated using the open street map road network distance from households to the treatment facilities. Analysis identified independent predictors of distance traveled and, for those bypassing their nearest clinic, the probability of accessing a tertiary care facility. Results: From September 2013 through December 2015, 3,666 HIV-positive participants were identified, of whom 98% received HIV Counseling and Testing (HCT), 74% were enrolled in HIV care, 63% had initiated ART, 92% of persons on ART were virally suppressed 12 months after initiating ART. Engagement in care and ART use were lower among men than women (enrollment in care: adjPRR 0.84, 95% CI 0.77–0.91; ART initiation: adjPRR 0.75, 95% CI 0.69–0.82), persons aged 15-24 compared with those aged 30-39 (enrollment: adjPRR 0.72, 95% CI 0.63–0.82; ART: adjPRR 0.69, 95%CI 0.60-0.80), unmarried persons (enrollment: adjPRR 0.84, 95% CI 0.71–0.99; ART adjPRR 0.80, 95% CI 0.66–0.95), and new in-migrants (enrollment: adjPRR 0.75, 95% CI 0.67–0.83; ART: adjPRR 0.76, 95% CI 0.67–0.85). We assessed the UNAIDS ’90-90-90’ targets to be 98%-65%-92% as of 2015, and estimate that 58% of the entire HIV-positive population was virally suppressed. Modest but statistically significant differences in several high-risk sexual behaviors were observed between those who were and were not enrolled in care or on ART. Enrollment into HIV care was lower among persons with non-marital sexual partners (adjPRR 0.92, 95% CI 0.85–1.00) compared to those without 95% CI 0.72–0.99). ART use was also lower in persons with non-marital sexual partners (adjPRR 0.88, 95% CI 0.81–0.96), persons with sexual partners outside the community (adjPRR 0.89, 95% CI 0.80–0.99), and among fisherfolk (adjPRR 0.78, 95% CI 0.64–0.94). From February 2015 and September 2016, 1554 HIV-positive participants in the RCCS were identified, of whom 1030 (66%) had initiated ART and provided information on where they received treatment services. The median distance from households to the nearest ART facility was 3.10 km (Interquartile range, IQR, 1.65-5.05). However, we found individuals traveled significantly further, traveling a median 5.26 km for ART treatment, p<0.001, (IQR, 3.00-10.03), and 57% of patients (589/1030) chose to travel to a facility further than their nearest facility. Those with higher levels of education and wealth were more likely to travel further and to access higher level services, compare to persons with lower education and affluence. We found the majority 963/1030 (93%) on ART were virally suppressed and found no difference in the distance traveled to an ART facility between those suppressed and the unsuppressed (5.26 km vs. 5.27 km, p=0.650). Conclusions: We documented important successes in the areas of HIV diagnoses, ART initiation, and viral suppression. However, interventions are needed to promote enrollment of hard to reach and high-risk groups like HIV-positive males, younger individuals, and in-migrants into HIV care. We found substantial heterogeneity in the distance to the nearest treatment facility; however, distance to the nearest treatment factility was not predictive of community ART coverage and found that virologic outcomes among those on ART did not vary by distance traveled for treatment. Our finding that persons with high-risk profiles were less likely to initiate ART suggests one reason why HIV epidemics in some regions have not been substantially mitigated despite scale-up of HIV treatment. Engaging these priority populations will require new resources and strategies in order to meet global targets for ART initiation, retention, and viral suppression.