Abstract Book Vol. 1 [International Conference on AIDS (16th: 2006: Toronto, Canada)]

Tuesday
15 August
Poster
Exhibition

TUPEO212
Cost-effectiveness analysis of modified directly
observed therapy (MDOT) for HAART for
patients with poor adherence in the adherence
to antiretroviral therapy for substance abusers
(AARTS) trial
M. Mwamburi, G. Macalino2, I. Wilson2, J. Mitty3, J. Griffith2, P. Neuman2,
C. Wankel, T. Flanigans, J. Wong2. 1Tufts University, School of Medicine,
Public Health and Family Medicine, Boston, United States, 2Tufts-New England
Medical Center, Institute of Clinical Research and Health Policy Studies,
Boston, United States, 3Miriam Hospital, Infectious Diseases, Providence,
United States
Background: The long-term clinical benefits and cost-effectiveness of MDOT
remain controversial. We estimated the incremental cost effectiveness ratio
(ICER) of 3 months of MDOT compared to standard of care (SOC) using clinical
trial data.
Methods: The AARTS trial, conducted in Providence, Rhode Island, compared
MDOT to SOC in HAART experienced, substance users. We developed regression
models for 3-month viral load and CD4 count outcomes. Using Egger's Weibull
survival model for HIV disease, 3-month outcomes were extrapolated into longterm HIV outcomes. We estimated quality adjusted life expectancy in years
(QALY) and lifetime medication and health utilization costs, discounted 3%
annually, to compute the ICER in US$/QALY gained with MDOT, compared to
SOC. Medication and health utilization costs were obtained from the 2004 Red
Book and the HIV Cost and Services Utilization Study, respectively.
Results: MDOT reduced viral load by 1.02 log10 copies/mL (p=0.01), raised
CD4 by 81 cells/mL (p<0.01). There was a trend toward lower HIV resistance
for MDOT compared with SOC (11% vs. 30%, p=0.17). MDOT cost US$ 1,500/
month to implement 3 months of MDOT cost approximately US$ 4,000 per
log10 decrease in viral load (including HAART and healthcare utilization costs).
MDOT yielded 13.6 QALY (cost=US$ 41,718) while SOC yielded 12.5 QALY
(cost=US$ 40,868), for an ICER of US$ 833/QALY. In multivariate sensitivity
analyses based on incremental viral load and CD4 count outcomes and the
shape parameter in the Weibull survival curve, the ICER ranged between US$
200 and US$ 1,000. CD4 count and HIV healthcare utilization costs were the
most influential parameters.
Conclusions: Three months of MDOT conferred both immediate and long-term
clinical benefits in the population we studied, and was highly cost-effective.
Studies that examine other populations, and use longer follow-up times, are
needed to better understand the generalizability of these findings.

TUPEO214
ART delivery as part of a continuum of HIV care
services in Tanzania
E. van Praag', G. Mpangile', R. Swain, B. Bwijo2, V. Mmbaga3,
F. Mwanga4. 'Family Health International, Institute for HIV/AIDS, Dar es
Salaam, Tanzania, United Republic of, 2Ministry of Health, National AIDS
Control Programme, Dar es Salaam, Tanzania, United Republic of, 'Deloitte/
Family Health International, Iringa Regional Hospital, Iringa, Tanzania, United
Republic of, 4World Health Organization, Tanzania Country Office, Dar Es
Salaam, Tanzania, United Republic of
Issues: Scaling up access to ART through existing health service delivery
systems depends on critical system factors such as commodity management,
human resources, health service organization and inclusion of community
support services. So far externally supported programs focus on training, drug
purchasing and laboratory strengthening. Sustainability and scaling up will
depend, however, on harmonization of all these health service factors
Description: Within 18 months, the NACP with support of 17 international
technical partners has built extensive capacity in HIV care and treatment by
developing national guidelines for Management of HIV/AIDS, certifying 200
hospital sites, training 1800 care providers from those sites, implementing
a standardized monitoring system from 96 sites and drafting a national
standard operating procedures guide. Through the NGO sector home based
care was strengthened to include adherence counseling, by training about
2,000 volunteers from 23 CBOs reaching 20,750 PLHAs. Referral systems have
been built between HBC programs and Care and Treatment Centres in order to
rapidly capture PLHAs ready for treatment. Sites show between 20 and 50%
of new patients eligible for ART being referred from or accompanied by HBC
volunteers.
Lessons learned: Sustained and rapid scale up requires both an intervention
and a systems approach. Tanzania with its external partners show this to be
feasible whereby CBO's play a crucial role allowing entry in the care continuum
and comprehensive support. Standardization of procedures assures quality and
sustainability.
Recommendations: HIV care and support service delivery across a continuum
from home/community to facility based care involving a variety of organizations
and facilities is feasible and can ensure that comprehensive needs of people
and households affected by HIV/AIDS can be met. Standardized approaches for
implementation with strong coordination between all partners involved in care
and treatment have shown to be practical in Tanzania and are recommended
elsewhere.

TUPEO213 TUPEO215
Equity of access to HIV services among HIV-infected Men's sexual health testing and health services at
individuals in England and Wales gay bars

B. Patel, T. Chadborn, V. Delpech. Health Protection Agency Centre for
Infections, HIV and STI Department, London, United Kingdom
Background: Patients can access the HIV service of their choice in England
and Wales, where treatment and care is free. Black-African heterosexuals and
people resident outside London account for much of the recent large increase
in numbers of HIV patients.
Methods: The Health Protection Agency conducts an annual, residence-based,
cross-sectional survey of HIV-infected individuals who attend HIV services.
We analysed available data for evidence of unequal access to services. We
compared the proportion of patients who used their nearest services as a proxy
marker for equity of access to care (using multivariable logistic regression).
Patients' place of residence were allocated deprivation scores according to
established criteria.
Results: Both place of residence and place of care were reported for 77%
(27,197) of patients in 2003. Clustering of centres and patients was observed
within large cities such that the average distance to local services was
3.5km, although 15% of patients lived more than 10km from their nearest
services. The individuals most likely to use their nearest services were those
living outside London (OR 2.69 (2.51-2.88)), and in the 25% most deprived
areas (OR 2.38 (1.88-3.00)). However, 94% (415/441) of those in the most
deprived areas lived within 5km of a service compared to 72% (5813/8036)
in the least deprived areas. Those infected through blood were less likely to
use their nearest services (OR 0.53 [0.39-0.70]) than men who have sex with
men whereas injecting drug users (1.40 [1.18-1.67]) and heterosexuals (men:
1.30 [1.18-1.43]; women: 1.40 [1.27-1.54]) were more likely. There was little
difference by ethnicity and age.
Conclusions: Where a person lives and their risk group are important
determinants of local service use. Planners should ensure that services are
adequate and targeted to meet the needs of local populations, taking into
account the reasons given by HIV-infected individuals for not accessing their
nearest services.

C.A. O'Connor', C.A. Patsdaughter2, D.V. Lessard3, M.J. Gaucher3. 'Northeatern
University, School of Nursing, Bouve College of Health Sciences, Milton, MA,
United States, 2Florida International University, PhD in Nursing Program,
College of Health and Urban Affairs, Miami, United States, 'Massachusetts
Department of Public Health, HIV/AIDS Bureau, Boston, United States
Issues: National data in the USA reveal that men who have sex with men,
including men who are not gay identified, have experienced an increase in STDs
since the late 1990s.
Description: This paper reports on an innovative mobile model that targets
MSM to be screened for HIV and STDs; vaccinated for hepatitis A and B and
influenza; and offered referrals for health care services and entitlements.
This model is a collaboration between a state health department, university
based school of nursing, and ASOs. Traditional and non-traditional recruitment
strategies are used. As of February 2006, the van has targeted six bar sites in
five cities, and 374 individuals have received services. MSM have been screened
for HIV (n=252), syphilis (n=212), and chlamydia (n=192). Additionally,165
HAV, 133 HBV, and 67 influenza immunizations were administered. Sixty-four
referrals were made including 3 for STD treatment, 6 for HIV testing off the
van, 39 for primary care services, 4 for mental health services, 1 for substance
abuse treatment, 1 to a SEP, and 10 for health insurance. Harm reduction
educational sessions were also provided.
Lessons learned: MSM are more likely to get screened for STDs and be
vaccinated for communicable diseases if access to services is made possible
where they live, recreate, or congregate.
Recommendations: Collaborative, creative efforts such as this model provide
a way to meet public health goals of illness prevention and can be replicated
with impressive yields.
TUPEO216
Access to paediatric antiretroviral therapy for
children in rural communities in Mali
A. Sy, J. Segurado. Plan, Mali, Bamako, Mali
Issues: anti-retroviral drugs for children are provided free of charge in Mali
but not the related tests. In 2004, treatment services were provided only in
Bamako, excluding poor children from rural communities.
The Government of Mali plans to expand ART services to 55 health facilities
by 2009. This will only be possible if diagnostic and treatment algorithms are
simplified.
Description: In 2004, we established a Reception Centre in Bamako in
cooperation with the Fondation pour I'Enfance, with an accommodation capacity

XVI INTERNATIONAL AIDS CONFERENCE * 13-18 AUGUST 2006 * TORONTO CANADA * ABSTRACT BOOK VOLUME 1