Slide1: BACKGROUND METHODS RESULTS CONCLUSIONS ACKNOWLEDGEMENTS According to UNAIDS, 8.9 million men, 13.1 million women, and 2.1 million children andlt; 15 years old are infected with HIV in sub-Saharan Africa . Scale-up of HIV/AIDS care and treatment has gained tremendous momentum over the past few years with successful enrollment of large numbers of HIV-infected patients in multiple resource-limited countries in sub-Saharan Africa. There is little information, however, on whether the number of men, women and children accessing care and treatment is proportionate to the numbers affected by the epidemic. Through funding from the U.S. Centers for Disease Control and Prevention under the President’s Emergency Plan for AIDS Relief (PEPFAR), the International Center for AIDS Care and Treatment Programs (ICAP) at the Columbia University's Mailman School of Public Health supports HIV/AIDS prevention, care, and treatment programs, including provision of antiretroviral therapy (ART), when indicated, at 200 sites in 7 sub-Saharan countries, namely Ethiopia, Kenya, Mozambique, Nigeria, Rwanda, South Africa and Tanzania (Figure 1). Routinely collected data on the number of men, women and children enrolled in care and on ART at ICAP-supported programs in these countries, in conjunction with UNAIDS estimates of the number of HIV-infected men, women and children per country, allowed investigation of whether there are differences in access to care and treatment by age and sex. On a quarterly basis from July 2004 – March 2007, aggregate data on a standardized set of Office of the Global AIDS Coordinator (OGAC) indicators were collected by in-country Monitoring andamp; Evaluation Officers, transmitted to ICAP-New York via a web-based system and cleaned by New York-based staff. The primary data elements from these routinely collected indicators used in this analysis include: Cumulative number of patients enrolled in care and enrolled on ART by sex and age (i.e. andlt;15 vs. 15+ years of age); and Cumulative number of ART patients known to have died or lost-to-follow-up by sex and age (i.e. andlt;15 vs. 15+ years of age). These data elements were used to calculate the proportion men, women and children among those cumulatively enrolled in care and on ART at ICAP-supported sites within and across countries. In 2005, UNAIDS provided estimates of the number of men, women and children with HIV in each country. These estimates were used to calculate the proportion men, women and children among those HIV-infected population in each country. Access to HIV care and treatment by sex and age was determined by comparing the proportion of each subgroup cumulatively enrolled in care and enrolled on ART to the proportion of each subgroup among those HIV-infected as estimated by UNAIDS, referred to as the program to population ratio in this analysis. Program to population ratios are presented relative to a line of equality (e.g. age/sex proportional enrollment in ICAP-supported programs matches that of UNAIDS for each subgroup). Ratios for a specific subgroup that are andlt;1 appear below the line of equality, indicating that individuals in that subgroup are not accessing ICAP-supported services, while ratios that are andgt;1 appear above the line, suggesting that individuals in that subgroup are over-represented in ICAP-supported programs relative to their proportional burden of disease at the country level. From July 2004 through March 2007, a total of 229,735 HIV-infected patients were enrolled in HIV care and 108,394 were initiated on ART at 200 sites in Ethiopia, Kenya, Mozambique, Nigeria, Rwanda, South Africa and Tanzania (Figure 2). Of all patients enrolled in care, 30% (range across countries 26-33%) were men, 59% (range: 54-67%) were women, and 11% (range: 7-13%) were children. Of those on ART, 33% were men (range: 29-42%), 58% (range: 52-66%) were women, and 9% (range: 3-10%) were children (Table 1). After adjusting for the number of patients in each country program, the overall program to population ratio for men enrolled in care was 0.76 (range: South Africa 0.65 – Ethiopia 1.05), with all country programs but Ethiopia under-enrolling men relative to their proportional burden of disease at the national level. (Figure 3). A similar pattern was observed for ART where the program to population ratio for men was 0.83, with South Africa (0.70) and Ethiopia (1.16) again having the lowest and highest ratios, respectively (Figure 4). In contrast, in all countries women successfully enrolled in care (Figure 5) with an overall program to patient ratio of 1.18 and less variation was observed across countries (range: Mozambique 1.02 – Rwanda 1.24) than was the case for men. Similarly, across all countries the program to patient ratio for treatment was 1.18 and ratios by country were all near or above 1 (range Mozambique 0.96 – Rwanda and Tanzania 1.22) (Figure 6). For children enrolled and on ART, the program to population ratios were 1.21 and 1.03, respectively with significant variation across countries (Figure 7). In Ethiopia these figures were 0.57 and 0.23, respectively, whereas in South Africa, they were 1.75 and 2.25 (Figure 8). Age and Sex Distributions of Patients Enrolled in HIV Care and Treatment Programs Compared with that of the HIV Epidemic in 7 sub-Saharan African Countries D Nash1, C Korves1, B Elul1, M Rabkin1, Josué Lima1, Doris Macharia1, D Hoos1, T Ellerbrock2, W El Sadr1 1 International Center for AIDS Care andamp; Treatment Programs (ICAP), Columbia University Mailman School of Public Health, New York, New York, U.S.A. 2 Global AIDS Program, Center for Disease Control and Prevention, Atlanta, Georgia, U.S.A. HIV program to population ratios of HIV-positive men, women, and children are an important measure of access to care and suggest that women and children are successfully accessing HIV care and ART in ICAP-supported programs across multiple countries and settings. However, it appears that there may be fewer opportunities for males to enroll in HIV care and treatment, suggesting that additional efforts are needed to increase enrollment of adult males. Additionally, the lower program to population ratio of men enrolled in care when compared to the comparable ratio of men on ART suggests that when men do access care they are sicker than women and children. High mortality among children enrolled in care who have not yet initiated ART may explain the higher program to population ratio of children enrolled in care when compared to the ratio of children on ART, as may difficulties in procuring pediatric ART regimens. Partners organizations including: Federal Ministry of Health, Ethiopia; Ministry of Health, Nigeria; Ministry of Health, Kenya; Ministry of Health, Mozambique; Treatment and Research AIDS Center, Ministry of Health, Rwanda; Provincial Health Department of the Eastern Cape, South Africa; Ministry of Health, Tanzania Government staff at the 200 ICAP-supported sites ICAP staff in-country and in New York CDC and USAID staff in the United States and Africa The individuals and families with HIV receiving services at ICAP-supported sites Funding support: United States Centers for Disease Control and Prevention (CDC) Figure 3: ICAP Male Enrollment in HIV Care by Country Relative to National Estimates of Men with HIV* Figure 4: ICAP Male ART Enrollment by Country Relative to National Estimates of Men with HIV* Figure 5: ICAP Female Enrollment in HIV Care by Country Relative to National Estimates of Women with HIV* Figure 7: ICAP Child Enrollment in HIV Care by Country Relative to National Estimates of Children with HIV* Figure 6: ICAP Female ART Enrollment by Country Relative to National Estimates of Women with HIV* Figure 8: ICAP Child ART Enrollment by Country Relative to National Estimates of Children with HIV* Table 1: Characteristics of patients enrolled in HIV care (pre-ART and ART) and on ART at ICAP-supported sites by country as of March 31, 2007 Figure 1. Columbia University/ICAP – PEPFAR supported countries. Figure 2. Cumulative enrollment in HIV care (pre-ART andamp; ART) and ART care at ICAP-supported facilities and number of facilities, October 2004 – March 2007