Rapid initiation of ART, treatment adherence support, proper management of virologic failure are important strategies for reaching the ambitious 90-90-90 goals in Ukraine and globally. Key national stakeholders and international donors have set ambitious fast track goals to increase the number of patients from 88,270 on 01/01/2018 to 140,000 by the end of 2018. This study was commenced to obtain reliable data on key treatment quality indicators, contributing factors and trends to inform program planning.
Data from medical charts of all patients who received care at HIV facilities in 2010-2016 in 18 out of 27 regions of Ukraine were entered into an electronic medical record system. After verification of data quality, depersonalized datasets linked by unique patient code were extracted at each facility and merged for analysis. This analysis focused on the effect of clinical variables (HIV mode of transmission, clinical stage, CD4, VL, TB, HCV, injecting drug use [IDU]) on time from diagnosis to ART initiation and to viral suppression (<200cp/ml). The entire dataset, excluding children younger than 15 at diagnosis, was analyzed using Cox proportional hazard models.
The cohort included 37,690 patients with HIV infection, approximately 30% of all patients receiving care in Ukraine in 2016. Average age at diagnosis 46.4% were females. Median time from diagnosis to ART was 26 months (95%CI: 25.0-26.9) and 14 months (95%CI: 13.7-14.3) from ART to viral suppression. Multiple significant predictors were identified for both outcomes (see Table). Notably, the time to ART initiation was increasing with male gender (aHR=.91), negative TB status (aHR=.9), being at early clinical HIV stage (aHR=.53), IDU mode of transmission (aHR=.77). The chance of getting ART was increasing with lower CD4 (aHR=4.1 for CD4<200), reporting no recent IDU (aHR=1.11), having positive TB test (aHR=1.18), homosexual mode of transmission (aHR=1.18). Viral suppression was associated with younger age (aHR=.98), earlier clinical stage (aHR=1.08), having negative TB test (aHR=.86), IDU mode of transmission (aHR=.93). Overall, coverage of key clinical assessments was not universal, and completion was associated with both outcomes.
Quality of HIV care in Ukraine, characterized by coverage of key clinical tests, time to ART initiation and viral suppression indicators remains suboptimal. Patients with advanced disease had priority for ART, reflecting the delayed adoption of test-and-start strategy.