Time to anti-retroviral therapy among people living with HIV enrolled into care in Myanmar: how prepared are we for ‘test and treat’?

Figures & data

Figure 1. Conceptual framework of delays in HIV care cascade, Myanmar, 2014–2016*.

HIV = human immunodeficiency virus, ART = anti-retroviral therapy

*Eligibility assessment delay and time spent in pre-ART care will not be applicable in a ‘test and treat’ setting (implemented since September 2017).

Figure 2. Flow chart on process of ART care for people living with HIV in ART clinics of the National AIDS Programme, Myanmar (2014–2016)*^†.

HIV = human immunodeficiency virus, ART = anti-retroviral therapy; AIDS = acquired immunodeficiency syndrome; HBV = hepatitis B virus; HCV = hepatitis C virus; TB = tuberculosis; WHO = World Health Organization

*Box in pink colour is relevant during ‘test and treat’ strategy (implemented since September 2017). Box in white colour will not be relevant after introduction of ‘test and treat’ strategy.^†Enrolled during 2014–2016 and followed up for ART initiation up to 5 December 2017; followed up until 31 March 2018 for attrition.

Table 1. Socio-demographic and clinical characteristics of people living with HIV enrolled at a public sector ART centre in Pyin Oo Lwin, Myanmar (2014–2016) (N = 543).

Variables	N	(%)
Total	543	(100.0)
Sex
Male	319	(58.7)
Female	224	(41.3)
Age in years
18–24	48	(8.8)
25–34	194	(35.7)
35–44	191	(35.2)
≥ 45	110	(20.3)
Mean (SD)	36.7	(9.7)
Risk factors
Heterosexual	318	(58.6)
MSM	3	(0.6)
FSW	7	(1.3)
IDU	61	(11.2)
Blood transfusion	12	(2.2)
Mother to child	1	(0.2)
Missing	141	(26.0)
Literate
No	76	(14.0)
Yes	377	(69.4)
Missing	90	(16.6)
Employed
No	125	(23.0)
Yes	331	(61.0)
Missing	87	(16.0)
Entry point
VCT	180	(33.1)
STI	1	(0.2)
TB clinic	2	(0.4)
Outpatient	158	(29.1)
Inpatient	67	(12.3)
Private	24	(4.4)
Self-referred	18	(3.3)
Drug Treatment Unit	3	(0.6)
Missing	90	(16.6)
CPT at enrolment*
No	254	(46.8)
Yes	289	(53.2)
TB at enrolment*
No	491	(90.4)
Yes	52	(9.6)
Year of enrolment
2014	170	(31.3)
2015	171	(31.5)
2016	202	(37.2)

HIV = human immunodeficiency virus, ART = anti-retroviral therapy, MSM = male who has sex with men, FSW = female sex worker, IDU = intravenous drug users, STI = sexually transmitted infection, TB = tuberculosis, VCT = voluntary counselling and testing, CPT = cotrimoxazole preventive therapy

*Until six weeks from date of enrolment.

Table 2. Socio-demographic and clinical characteristics of people living with HIV initiated on ART at a public sector ART centre in Pyin Oo Lwin, Myanmar (2014–2016) (N = 373)^†.

Variables	n	(%)
Total	373	(100.0)
Sex
Male	212	(56.8)
Female	161	(43.2)
Age in years
18–24	28	(7.5)
25–34	122	(32.7)
35–44	137	(36.7)
≥ 45	86	(23.1)
Mean (SD)	37.6	(9.7)
Risk factors
Heterosexual	269	(72.1)
MSM	2	(0.5)
FSW	4	(1.1)
IDU	48	(12.9)
Blood transfusion	10	(2.7)
Mother to child	1	(0.3)
Missing	39	(10.5)
Literate
No	62	(16.6)
Yes	309	(82.8)
Missing	2	(0.6)
Employed
No	103	(27.6)
Yes	268	(71.8)
Missing	2	(0.6)
Entry point
VCT	125	(33.5)
STI	1	(0.3)
TB clinic	2	(0.5)
Outpatient	145	(38.9)
Inpatient	58	(15.6)
Private	22	(5.9)
Self-referred	18	(4.8)
Drug Treatment Unit	1	(0.3)
Missing	1	(0.3)
WHO stage
Stage 1	155	(41.6)
Stage 2	75	(20.1)
Stage 3	61	(16.4)
Stage 4	17	(4.6)
Missing	65	(17.4)
CD4 count
<50	24	(6.4)
50–99	53	(14.2)
100–199	99	(26.5)
200–349	104	(27.9)
350–499	48	(12.9)
≥ 500	35	(9.4)
Missing	10	(2.7)
Median (IQR)	206	(109, 332)
Year of enrolment
2014	93	(24.9)
2015	127	(34.1)
2016	153	(41.0)

HIV = human immunodeficiency virus, ART = anti-retroviral therapy, MSM = male who has sex with men, FSW = female sex worker, IDU = intravenous drug users, STI = sexually transmitted infection, TB = tuberculosis, VCT = voluntary counselling and testing, WHO = World Health Organization; CPT = cotrimoxazole preventive therapy

^†Enrolled during 2014–2016 and followed up for ART initiation up to 5 December 2017.

*Until six weeks from date of enrolment.

Table 3. Time taken (days) for ART initiation from HIV diagnosis among people living with HIV enrolled at a public sector ART centre in Pyin Oo Lwin, Myanmar (2014–2016).

Time taken (days) in care cascade from HIV diagnosis	Eligible and assessed*	Median (IQR)	Range
Enrolment delay (a)	472	4 (1, 14)	0, 1105
Eligibility delay and/or time interval in pre-ART care (b)	373	4.5 (0, 13.3)	0, 559
ART initiation delay (c)	373	20 (13, 36)	0, 673
Time to ART (a + b + c)	330	39 (24, 74)	0, 1105
Time to ART after excluding the delay in eligibility and/or time interval in pre-ART care (a + c)	330	29 (18, 55)	0, 1105

HIV = human immunodeficiency virus, ART = anti-retroviral therapy; IQR = inter-quartile range

*543 were enrolled and 373 were initiated on ART as on 5 December 2017. Those who were eligible and dates were available were included.

Table 4. Factors associated with long time to ART* (≥ 30 days) after excluding the time interval in pre-ART care among people living with HIV initiated on ART at a public sector ART centre in Pyin Oo Lwin, Myanmar (2014–2016) (N = 373)^†.

Variables		Crude PR (0.95 CI)	Adjusted PR^# (0.95 CI)
Entry point at enrolment
	VCT	Ref	Ref
	STI/TB/Drug Treatment Unit	-^	-^
	Outpatient	0.87 (0.71, 1.08)	0.86 (0.70, 1.06)
	Inpatient	0.94 (0.72, 1.22)	0.89 (0.69, 1.16)
	Private/self-referred	0.70 (0.47, 1.03)	0.70 (0.48, 1.03)
	Missing	-^	-^
Prevalent TB at enrolment
	No	Ref	Ref
	Yes	1.39 (1.12, 1.71)**	1.42 (1.13, 1.79)**
CD4 count (microlitre) at ART start
	<50	Ref	Ref
	50–99	1.06 (0.66, 1.70)	1.22 (0.77, 1.93)
	100–199	1.11 (0.72, 1.72)	1.25 (0.83, 1.91)
	200–349	1.15 (0.75, 1.78)	1.34 (0.87–2.05)
	350–499	1.13 (0.70, 1.80)	1.36 (0.85, 2.19)
	≥ 500	1.31 (0.82, 2.10)	1.59 (1.00, 2.52)**
	Missing	-^^	-^^
Constant		-	0.46 (0.30, 0.70)

HIV = human immunodeficiency virus, ART = anti-retroviral therapy, STI = sexually transmitted infection, TB = tuberculosis, VCT = voluntary counselling and testing, PR = prevalence ratio, aPR = adjusted prevalence ratio, CI = confidence interval

^†Enrolled during 2014–2016 and followed up for ART initiation up to 5 December 2017.

*Combination of enrolment delay and ART initiation delay. We categorized the delay based on the median value.

^#Modified Poisson regression with robust variance estimates (forward stepwise method); other variables at enrolment (age, sex, HIV risk factor, literacy, employment status, cotrimoxazole preventive therapy status, year of enrolment) and at ART eligibility (WHO clinical staging) were considered in the model. However, they were excluded by the model as they did not significantly improve the model prediction.

^{^}Limited sample (n ≤ 10) in this sub-category.

**p < 0.05

Table 5. Outcomes among people living with HIV initiated on ART at a public sector ART centre in Pyin Oo Lwin, Myanmar (2014–2016) (N = 373)^†.

Outcomes	Initiated at enrolment*		Initiated after enrolment		Overall
	n	(%)	n	(%)	n	(%)
Total	245	(100)	128	(100)	373	(100)
Still on treatment	151	(61.6)	88	(66.7)	239	(64.1)
Transferred out	36	(14.7)	13	(10.2)	49	(13.1)
Death**	27	(11.0)	14	(10.9)	41	(11.0)
Loss to follow-up**	31	(12.7)	13	(10.2)	44	(11.8)

HIV = human immunodeficiency virus, ART = anti-retroviral therapy

^†Enrolled during 2014–2016 and followed up for ART initiation up to 5 December 2017; followed up until 31 March 2018 for attrition.

*Until six weeks from date of enrolment.

**Included under attrition.

Table 6. Cumulative incidence of attrition rate among people living with HIV initiated on ART at a public sector ART centre in Pyin Oo Lwin, Myanmar (2014–2016) (N = 373)^†.

Cohort	Person-days of follow-up	Attrition^^	Incidence density per year (%)	(0.95 CI)
Total	237,628	83	12.8	(10.2, 15.7)
0–100 days	33,545	43	46.7	(34.7, 63.1)
101–200 days	30,011	8	9.9	(4.7, 19.3)
> 200 days	174,072	32	6.6	(4.8, 9.5)

HIV = human immunodeficiency virus, CI = confidence interval

^†Enrolled during 2014–2016 and followed up for ART initiation up to 5 December 2017; followed up until 31 March 2018 for attrition.

^{^}Includes loss to follow-up and death.

Figure 3. Kaplan Meier survival curve^{^} among people living with HIV initiated on ART* at a public sector ART centre in Pyin Oo Lwin, Myanmar (2014–2016): overall and stratified by time to ART after excluding the delay in eligibility and/or time interval in pre-ART care*^†.

HIV = human immunodeficiency virus, ART = anti-retroviral therapyLog rank test P value = 0.325, ^{^}Event of interest is attrition which includes loss to follow-up and death.*Combination of enrolment delay and ART initiation delay, categorized based on the median value.^†Enrolled during 2014–2016 and followed up for ART initiation up to 5 December 2017; followed up until 31 March 2018 for attrition.

Table 7. Confounder adjusted association between various delays before ART initiation and attrition (death and loss to follow-up) among people living with HIV initiated on ART at public sector ART centre in Pyin Oo Lwin, Myanmar (2014–2016) (N = 373)^†.

Delay type*	Attrition**	HR (0.95 CI)	aHR (0.95 CI)^#
Enrolment delay (a)
Yes	7.4	0.64 (0.41, 0.99)	0.60 (0.37, 0.99)^^
No	12.1	Ref	Ref
Eligibility delay and time on pre-ART care (b)
Yes	12.4	0.93 (0.60, 1.43)	0.72 (0.42, 1.24)
No	13.1	Ref	Ref
ART initiation delay (c)
Yes	12.0	0.88 (0.57, 1.35)	0.71 (0.42, 1.20)
No	13.5	Ref	Ref
Time to ART (a + b + c)
Yes	10.6	0.72 (0.47, 1.12)	0.72 (0.44, 1.17)
No	15.3	Ref	Ref
Time to ART after excluding the delay in eligibility and/or time interval in pre-ART care (a + c)
Yes	11.7	0.81 (0.52, 1.24)	0.67 (0.40, 1.13)
No	14.2	Ref	Ref

HIV = human immunodeficiency virus, HR = hazard ratio; aHR = adjusted hazard ratio; CI = confidence interval

^†Enrolled during 2014–2016 and followed up for ART initiation up to 5 December 2017; followed up until 31 March 2018 for attrition.

*Median delay was used to categorize each delay type.

**Incidence density per year (%)/incidence density per 100 person-years, attrition includes death and loss to follow-up.

^#Cox regression (enter method); adjusted for CD4 count, WHO staging, literacy and employment status, entry point, HIV risk factors, year, prevalent TB, CPT use at enrolment, age and sex.

^{^}p < 0.05