ICAP-Columbia UniversityTrack 1.0 Program (MCAP)

Track 1.0 Meeting - MaputoAugust 2010

Outline of Presentation

• Key programmatic achievements• Need for continued scale-up and innovations

to aim for universal access• Focus on quality in the context of transition

– Loss to follow up and retention– Data quality assurance

• Transition activities for Track 1.0• Summary and conclusions

Key Programmatic Achievements

The spectrum of HIV related portfolio of activities for ICAP-CU

Num

ber o

f site

s

Note: Some sites offer more than one activity

Total dist

inct sit

es

Care & tre

atmen

t

TB screening fo

r HIV pts

HIV testin

g for T

B pts

PMTCT

Early in

fant d

iagnosis

PICT/VCT

Lab0

200

400

600

800

1,000

1,200

1,400

1037

507 474 310

879451

676385

182

180 147101

43

12414

69

Non-MCAPMCAP

3841238777391423950839873402380

100,000

200,000

300,000

400,000

500,000

600,000

700,000

800,000

900,000

1,000,000

0

100

HIV Care ART

Continued increase in number of ICAP-supported facilities and enrollment in HIV care and treatment

Ethiopia

Lesotho, Rwanda,S. Africa, Tanzania

Mozambique

Zambia Nigeria, Kenya

Cote d’Ivoire

652 facilities

861,280 ever enrolled in

care

Num

ber o

f pati

ents

Num

ber of facilities

430,876 ever initiated ART

Swaziland

3841238777391423950839873402380

100,000

200,000

300,000

400,000

500,000

600,000

700,000

800,000

0

100

HIV Care ART

Cumulative enrollment in HIV care and treatment at sites currently supported by MCAP (Track 1.0)

Ethiopia

RwandaS. Africa Tanzania

Mozambique

Nigeria, Kenya

Cote d’Ivoire

488 facilities

683,838 ever enrolled in

care

Num

ber o

f pati

ents

Num

ber of facilities

334,157 ever initiated ART

Continued increase in numbers of new enrollees in HIV care and treatment per quarter

Num

ber o

f new

pati

ents

Note: *New enrollment includes transfers

0

10,000

20,000

30,000

40,000

50,000

60,000

70,000

80,000

90,000

100,000

6,078

17,875

29,032

37,193

52,471 52,84660,440

73,566 72,580

84,28090,326

2,1075,457

12,42716,639

24,091 26,25729,484

36,838 36,032

45,89152,684

New care enrollment New ART enrollment

In each country, new ART enrollment rates are stable (site number constant)

Jan-Mar 2009 Apr-Jun 2009 Jul-Sep 2009 Oct-Dec 2009 Jan-Mar 20100

500

1,000

1,500

2,000

2,500

3,000

3,500

4,000

4,500

5,000Cote d'Ivoire (28 sites) Ethiopia (44 sites) Kenya (44 sites)Mozambique (41 sites) Nigeria (30 sites) Rwanda (46 sites)South Africa (30 sites) Tanzania (87 sites)

Num

ber o

f new

ART

pa

tient

s

38412 38777 39142 39508 39873 402380

10,000

20,000

30,000

40,000

50,000

60,000

70,000

80,000

0

100

200

300

400

500

600

700

HIV care ART

Increasing number of children enrolled in HIV care and treatment

Ethiopia

LesothoRwandaS. Africa Tanzania

Mozambique

Nigeria, Zambia Kenya

Cote d’Ivoire

652 facilities

73,367 ever enrolled in care

Num

ber o

f pati

ents

Num

ber of facilities

36,700 ever initiated ART

Swaziland

39142 39326 39508 39692 39873 40057 402380%

50%

100%

0

50

100

150

200

250

300

350

400

450

78%

66%

79%

88%

79%

88% 90% 90% 93% 94%85% 85% 83%

Proportion # facilities

Increasing proportion of new TB patients with unknown HIV status tested for HIV

Perc

ent o

f pati

ents

n=5,992 n=6,397 n=8,416 n=8,750 n=8,907 n=10,003 n=7,613TB patients with

unknown HIV status

Sep-07 Dec-07 Mar-08 Jun-08 Sep-08 Dec-08 Mar-09 Jun-09 Sep-09 Dec-09 Mar-100%

10%

20%

30%

40%

50%

60%

70%

0

100

200

300

400

500

600

40%

48%52%

57% 55%57% 56%

59%62% 61%

65%

Proportion # facilities

Increasing proportion of new patient enrolled in HIV care screened for TB

Perc

ent o

f pati

ents

n=22,037New HIV patients n=28,630 n=37,234 n=38,025 n=38,379 n=44,612

HIV testing and counseling (January-March 2010)

Source: ICAP URS March 2010 Notes: Data is not available for all indicators in all points of service. Not all countries are able to report enrollment into care and treatment

Num

ber o

f clie

nts

Series10

50,000

100,000

150,000

200,000

250,000

300,000

350,000

400,000

450,000

392,803 392,105

27,034 17,509

Pre-test counseled and tested

Received test results

HIV+ among those receiving results

HIV+ and enrolled in care and treatment

Aiming for Universal Access will require continued scale-up and

innovation

ART coverage of estimated PLHIV eligible for treatment-- Central Province, Kenya

Central Province0%

5%

10%

15%

20%

25%

30%

35%

40%

Thika; 11%

Nyeri; 9%

Muranga; 5%

Nyandarua, 4%

Kiambu; 3%

Kirinyaga; 3%

Expansion of access to newly eligible patients as per new WHO guidelines

ART eligibility after 12-months of follow-up at 27 ICAP-supported sites

CURRENT NATIONAL GUIDELINES REVISED 2009 WHO GUIDELINES  Most recent CD4 count

   <200

cells/µL200-349 cells/µL

≥350 cells/µL Missing

Total

Most recent WHO

Stage

IV573 238 329 670 1,810

1.5% 0.6% 0.9% 1.8% 4.8%

III3,080 2,285 3,398 3,084 11,847

8.3% 6.1% 9.1% 8.3% 31.8%

II1,771 1,728 3,079 1,987 8,565

4.8% 4.6% 8.3% 5.3% 23.0%

I1,401 1,897 4,416 2,936 10,650

3.8% 5.1% 11.9% 7.9% 28.7%

Missing579 495 1,185 2,047 4,306

1.6% 1.3% 3.2% 5.5% 11.6%

 Total

7,404 6,643 12,407 10,724 37,178

19.9% 17.9% 33.4% 28.8% 100.0%

ART eli-gible29%

Not eligible39%

Unknown32%

  Most recent CD4 count

    <200 cells/µL

200-349 cells/µL

≥350 cells/µL Missing Total

Most recent WHO

Stage

IV573 238 329 670 1,810

1.5% 0.6% 0.9% 1.8% 4.8%

III3,080 2,285 3,398 3,084 11,847

8.3% 6.1% 9.1% 8.3% 31.8%

II1,771 1,728 3,079 1,987 8,565

4.8% 4.6% 8.3% 5.3% 23.0%

I1,401 1,897 4,416 2,936 10,650

3.8% 5.1% 11.9% 7.9% 28.7%

Missing579 495 1,185 2,047 4,306

1.6% 1.3% 3.2% 5.5% 11.6%

 Total

7,404 6,643 12,407 10,724 37,178

19.9% 17.9% 33.4% 28.8% 100.0%

ART eli-gible58%

Not eligible20%

Unknown22%

11,209 (30%) of 37,178 patients started ART during follow-up

Overal

l

Cote d'Iv

oire

Ethiopia

Kenya

Mozambique

Nigeria

Rwanda

South Afric

a

Tanza

nia0%

50%

100%

59% 65%53% 60% 58% 64% 57% 62% 60%

33%30%

40% 28% 34%29%

32% 30% 33%

8% 5% 8% 12% 9% 6% 10% 8% 7%

Women >14 Men >14 Children 0-14

Continued need to reach more childrenPe

rcen

t ped

iatr

ic p

atien

ts o

n AR

T

n=39,385n=24,016 n=87,191n=50,911 n=71,608 n=28,387n=334,157 n=4,062 n=28,597

Jun-07 Sep-07 Dec-07 Mar-08 Jun-08 Sep-08 Dec-08 Mar-09 Jun-09 Sep-09 Dec-09 Mar-100%

50%

100%

39% 45% 41% 45% 39% 38%28% 22% 26%

18% 14% 19%

46%43% 52% 44% 49% 52%

61% 68% 65%72%

72% 68%

15% 11% 8% 11% 12% 11% 11% 10% 10% 10% 14% 14%

Decrease in use of SD-NVP at ICAP-supported PMTCT programs but need to expand ART use, 2007-2010

Perc

ent (

%) o

f HIV

+ P

regn

ant

Wom

en

Multi-drug ARV prophylaxis

sdNVP

ART

38412 38777 39142 39508 39873 402380%

5%

10%

0.1%

1.2%

3.1%

4.6%

8.9%

6.8%

Pregnant women as a proportion of all women initiating ART

Perc

ent o

f w

omen

HIV testing must be focused to reach undiagnosed individuals

‘Hot spots’ exist within regions (overall HIV prevalence and clinic VCT HIV prevalence)

New initiatives need to be scaled-up

• Prevention in positives• Male circumcision (neonatal and

adult/adolescent)• Interventions for most at risk populations

– Drug users– Men who have sex with men– Adolescents

Implementing Partners and Districts Need to Focus on Quality,Retention and Loss-to-follow-up

Retention rates on ART from two meta-analyses of data from sub Saharan Africa

2009: 70% at 24 months

2007: 60% at 24 months

Fox and Rosen, Tropical Med Intl Health 2010

ICAP ART retention compared to findings from Rosen 2007 & Fox 2010 Meta-Analyses

0 0.5 1 1.5 250%

60%

70%

80%

90%

100%

ICAP ART 2009Rosen 2007Rosen 2010

Time (Years)

% o

f Pati

ents

Ret

aine

d in

Tre

atm

ent

ICAP ART Pt-Level Data, 2007-2009, N = 91,612 patients

Fox 2010

Focusing solely on ART patient is traditional approach to retention and follow up

Dx ART

ART in-eligible

ART eligiblePre-ART

Lost-to-follow-up:Death, Stopped care, Transfer, Unknown

ICAP Focus on Retention

Dx Pre-ARTART

ART in-eligible

ART eligible

HIV Care and Treatment

CHRONIC CARECHRONIC CARE

Retention across the continuum of HIV diagnosis, care and ART

Dx ART

ART in-eligible

ART eligiblePre-ART

Lost-to-follow-up:

Death, Stopped care, Transfer, Unknown

Use of aggregate data to evaluate retention

• Routinely collected in all country programs• Data quality limited by:

– Dependent on ‘status’ designation– Limitations of data in registers

• Currently only retention data is available for patients who initiated ART

38412

38777

39142

39508

39873

40238

0

50,000

100,000

150,000

200,000

250,000

300,000

350,000

400,000

450,000

500,000

Reported dead

Lost to follow up

Cumulative ever initiating ART

ART patients currently retained in HIV care*

Cumulative patients initiating ART and their current status (n= 430,876)

Num

ber o

f pati

ents

Continued ART* 354557

82%

Discontinued ART 76,319

18%

33%

64%

9.1% per year on

ART

Status of ART patients, as of March 31, 2010(n= 430,876)

.44% per year on

ART

4.7% per year on

ART

Lost to Follow-up

Reported Dead

Reported stopped ART 3%

Notes: *Includes patients who transferred out while on ART.

Rates

Use of patient-level data to evaluate retention

• Cohort data of pre-ART and ART patients• LTFU data based on clinic, pharmacy or lab

visits• Five countries, ~235,000 patients, 100 sites• Disposition of patients still influenced by

availability of active follow-up

Two-year cumulative risk of death, loss to follow-up9, and loss to program8

among ART patients since ART initiation (Total 113,000 patients); through March 2010

ART Patients at ICAP-supported sites(Patient-level data)

77% Retained at 2 years

High retention of pediatric ART patients Rwanda through March 2010 (n= 30 sites)

90% Retained at 2 years

Pre-ART Patients All Patients(Adult and Pediatric) through March 2010 (n= 185,898)

52% Retained at 2 years

66% retained at 6 mo

Better retention at rural versus urban sites

Better retention since ART initiation at primary health facilities versus secondary or tertiary facilities

Sites offering on-site patient support services that could influence retention (n=323)

% si

tes w

ith se

rvic

e

ART Adher-ence Support

Outreach Peer educa-tor program

Food support for children and infants

Food support for adults

0%

50%

100% 98%

57%

33% 37%

22%

Total (N = 324)

Cote d'Ivoire (N = 10)

Ethiopia (N = 24)

Kenya (N = 91)

Lesotho (N = 18)

Mozambique (N = 23)

Nigeria (N = 27)

Rwanda (N = 44)

South Africa (N

= 32)

Swaziland (N = 12)

Tanzania (N = 43)

0

20

40

60

80

100

Phone calls/letters (%) Home visits (%) Check hospital records (%)

% o

f site

sFirst step in tracing patients with missed ap-

pointments (PFaCTS)

ICAP Data Quality Assurance (DQA) Indicators

• Standardized DQA will assess the completeness and accuracy of key routinely reported indicators

• Programs will modify/incorporate standardized approach into routine DQA exercises

• ICAP-wide DQA indicators will be reported every other quarter for a specified past quarter of interest

• Findings will inform transition of collection of high quality data at Districts

DQA IndicatorsRoutinely Reported Indicator Data

SourceDQA Sample for Quarter of Interest

Gold Standard

DQA Indicator Denominator

DQA Indicator Numerator (completeness base on gold standard)

% Eligible patients receiving CTX when enrolling in HIV care*

Pre-ART Register

Random sample Clinical File

# in CTX eligible in DQA sample

# with documented CTX

% HIV+ children <1 yrs of age receiving ART*

Pre-ART Register

All Children <2 yrs

Clinical File

# in DQA sample

# with documented ART start date

% Patients enrolled in ART who remain in care for 6 of 6 months*

ART Register

Random sample from respective 6-mo cohort period

Clinical File

# in DQA sample

# with documented visit 6 of 6 months

% Patients in HIV care and treatment receiving TB screening at enrollment*

Pre-ART Register

Random sample Clinical File

# in DQA sample

# documented TB screening at enrollment

% HIV+ pregnant women in PMTCT services receiving multi-drug prophylaxis*

PMTCT Register

All HIV+ pregnant women

ANC Register

# in DQA sample

# with documentation of multi-drug prophylaxis

* Quality Indicator

Track 1.0 transition efforts

Examples of transition activities

• The size and scope of subcontracts with local government are increasing

• Institutional capacity building of local government is a particular focus – success here will be the eventual test of transition

• Intermediate stage of transition to local NGO

Summary

• Continued expansion of enrollment and programmatic diversity

• Urgent continuing need to expand coverage and reach new populations

• Expansive vision of retention in program• Data quality is a priority to inform programs• Country specific approaches to transitioning to

local partners

The Emergency is not over!

Work must continue to reach universal access to high quality

prevention and care