ICAP: SUCCESS AS A TRACK 1.0

IMPLEMENTING PARTNER

November 16, 2011

ABOUT ICAPICAP was founded in 2004 at Columbia University’s Mailman School of Public Health. Now a global leader in HIV/AIDS services, ICAP has supported work at more than 2,000 sites across 21 countries around the world. More than one million people have received HIV services through ICAP-supported programs.

ICAP’s support extends beyond direct provision of HIV services to help improve strategic planning, infrastructure, management, training, clinical mentorship, supportive supervision, quality improvement, laboratories, medical records, pharmacy systems, and monitoring and evaluation.

ORGANIZATIONAL STRUCTURE

ICAP-NY Headquarters• Situated at the Mailman School of

Public Health at Columbia University

• Expertise in program development, implementation, research and student training

• Responsibility for administrative, financial, strategic planning and development functions

Country Programs• Large country teams under

leadership of country directors• Provide national, regional, facility

and community level support• Expertise in capacity building:

program implementation, logistics, clinical issues, laboratory services, administration, financial management, monitoring and evaluation

WHERE ICAP WORKS• Cameroon*• Côte d’Ivoire• Democratic Republic of the Congo• Ethiopia• Dominican Republic*• Kazakhstan• Kenya• Kyrgyzstan• Lesotho• Malawi• Mali• Mozambique• Nigeria

• Rwanda• South Africa• Swaziland• Tajikistan• Tanzania• Thailand*• United States• Uganda*• Zambia

Notes: Bold indicates countries with ICAP offices. * Country ICAP has supported in the past

WHERE ICAP WORKSTUNISIA

MOROCCO

SAHARA

ALGERIA

MAURITANIA

NIGER

LIBYA

CHAD

EGYPT

SUDAN

ETHIOPIA

DJIBOUTI

ERITREA

SOMALIAKENYA

TANZANIA

DEMOCRATIC

CENTRAL

RWANDA

GABON

EQUATORIAL

ANGOLA

CONGO

NIGERIABENIN

D’IVOIRESIERRA

SENEGAL

GHANA

THE

GUINEA

LIBERIA CAMEROON

MALAWI

ZAMBIA

MOZAMBIQUE MADAGASCARZIMBABWE

BOTSWANA

SWAZILANDLESOTHO

NAMIBIA

ANGOLA

WESTERN

UGANDA

OF THE CONGO

REPUBLIC

BURUNDI

GUINEAREP. OF

TOGOCOTE

BURKINAGUINEA

LEONE

GAMBIA

BISSAU

SOUTH

REPUBLIC

AFRICAN

THE

AFRICA

*Denoted by countries in light blue

MADAGASCAR

MALI

OVERVIEW OF ICAP PROGRAM ACCOMPLISHMENTS

ICAP SUPPORTED SERVICES AT THE

FACILITY LEVEL

ICAP SUPPORTED FACILITIES IN KENYA, BY TYPE OF SERVICES

ICAP SUPPORTED HIV COUNSELING AND TESTING IN

MOZAMBIQUE ICAP SUPPORTED LABORATORIES IN ETHIOPIA

Total distinct facilities

Care & treatment

TB screening for HIV pts

HIV testing for TB pts

PMTCT Early infant diagnosis

PICT/VCT Lab0

200

400

600

800

1,000

1,200

1,400

1,600

1,800

1540

530 583

397

1156

858 1,010

548

ACTIVITIES AT TRACK 1.0SUPPORTED FACILITIES, JUNE 30, 2011

Num

ber o

f fac

ilitie

s

Source: ICAP Site Census, June 2011Note: Some facilities offer more than one activity.

ACTIVITIES AT ALL ICAP SUPPORTED FACILITIES,

JUNE 30, 2011

Num

ber o

f fac

ilitie

s

Source: ICAP Site Census, June 2011Note: Some facilities offer more than one activity.

Total distinct facilities

Care & treatment

TB screening for HIV pts

HIV testing for TB pts

PMTCT Early infant diagnosis

PICT/VCT Lab0

500

1,000

1,500

2,000

2,500

2284

763 807

576

1823

1053 1,010

723

ICAP ACCOMPLISHMENTS: HIV CARE AND TREATMENT

• More than 1.3 million patients enrolled into HIV care in ~900 facilities– 650,000 (50%) patients initiated ART

– 56,000 (9%) ART patients were <15 years of age

– 380,000 (71%) of 534,000 patients enrolled in facilities reporting TB screening data were screened for TB at enrollment

38443

38808

39173

39539

39904

40269

40634

0

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

CUMULATIVE ENROLLMENT IN HIV CARE AND TREATMENT AT FACILITIES EVER

SUPPORTED IN TRACK 1.0

Source: ICAP URS June 2011.Notes: Data are only from clinics supported and reporting. The country arrows depict when the country began contributing data.

*Data for Kenya includes Central Province only.

Num

ber o

f pat

ient

s Number of clinics484,617

on ART

941,819 in care

584clinics

Kenya*,Mozambique

Rwanda,S. Africa, Tanzania

Ethiopia

Nigeria

Côte d’Ivoire

38443

38808

39173

39539

39904

40269

40634

0

200,000

400,000

600,000

800,000

1,000,000

1,200,000

1,400,000

0

100

HIV Care ART

CUMULATIVE ENROLLMENT IN HIV CARE AND TREATMENT AT FACILITIES EVER

SUPPORTED BY ICAP*

Source: ICAP URS June 2011.Notes: The country arrows depict when the country began contributing data. *Does not include facilities funded through the MTCT Plus mechanism.

Num

ber o

f pat

ient

s Number of clinics

649,880 on ART

1,292,079 in care

898clinics

Kenya,Lesotho,

Mozambique Rwanda,S. Africa, Tanzania

Ethiopia

Côte d’Ivoire

Nigeria, ZambiaSwaziland

1/1/20

05

1/1/20

06

1/1/20

07

1/1/20

08

1/1/20

09

1/1/20

10

1/1/20

110%

25%

50%

75%

100%

0

100

200

300

400

500

600

80%, 295

79%, 19384

83%, 95

73%, 20343

Reporting Quarter

Perc

ent r

etai

ned

Number of clinics

SUSTAINED COHORT RETENTION (6 AND 12 MONTHS) AFTER ART INITIATION AT

SUPPORTED FACILITIESTrend : P=0.7299

Trend: P=0.0844

Source: ICAP URS June 2011Note: Significance testing for trend analysis reflects crude RR of retention per 1 unit increase in reporting quarter.

Percent retained 6 monthsPercent retained 12 monthsNumber of clinics reporting cohort data

• 1.8 million pregnant women HIV tested at ANC in ~ 1,700 facilities– 113,000 (6%) women tested positive + 20,000 (1%)

known positive

– 96,000 (72% of all positive) women received ARV prophylaxis, including 12,000 who received triple therapy

ICAP ACCOMPLISHMENTS: PMTCT

39234 39600 39965 40330 406950

50,000

100,000

150,000

200,000

250,000

0

200

400

600

800

1000

1200

1400

1600

1800

ANC visit Tested Number of facilities

NUMBER OF PREGNANT WOMEN ATTENDING ANC AND RECEIVING HIV

TESTING, BY QUARTER

Source: ICAP URS June 2011. The country arrows depict when the country started contributing data.

1,668 clinics

122,011 HIV tests

215,120 ANC visits

Num

ber o

f wom

enN

umber of clinics

S. Africa

Côte d’Ivoire

Mozambique, Rwanda,Ethiopia,Nigeria,Tanzania

Kenya

• 3.7 million people tested for HIV in ~1000 facilities

• 304,154 HIV-infected patients screened for TB-related symptoms upon enrollment into HIV care and treatment.

– 41,577 diagnosed with TB and initiated TB treatment at these facilities

• ~1 million HIV simple rapid tests and ~650,000 CD4 count tests processed in ~500 laboratories

ICAP ACCOMPLISHMENTS: HIV TESTING AND COUNSELING, TB/HIV,

AND LABORATORY SERVICES

KNOWLEDGE MANAGEMENT APPROACHES

Unified reporting system (URS):

• Web-based data system that captures and disseminates routine monitoring data from multiple ICAP-supported activities and programs at ICAP-supported sites

• Automated reports allow for real-time use of data for program monitoring and evaluation

• Technical assistance provided to country programs and MoH to develop similar databases for aggregate data collection, reporting and use

KNOWLEDGE MANAGEMENT TOOLS (1)

Patient-level data warehouse

• Warehouse captures a minimum set of HIV care and treatment and TB screening data elements from diverse country-level patient databases

• Automated reports generated to feedback information to sites on patient characteristics and clinical outcomes

• Technical assistance provided to country programs and MoH to develop and enhance patient level data collection systems for reporting and clinical care

KNOWLEDGE MANAGEMENT TOOLS (2)

ICAP PATIENT-LEVEL DATA WAREHOUSE ELEMENTS

Enrollment Table• Basic

demographic information • Age• Sex• enrollment

date• Prior ARV use• Point of entry• Transfer

Visit Table: Visit date, WHO stage, CD4 count & percent, height, weight, Hb, ALT, next scheduled visit date

Medication and pregnancy Table: ART regimen, regimen start & end date, regimen switch and reason, TB screening date and result, TB, cotrimoxazole, and fluconazole medication dates, Pregnancy status, weeks gestation, due date, actual pregnancy end date

Status Table: Patient disposition status (dead, transferred, withdrew, LTF, stopped ART, etc) and status date

Baseline: 1 rowper patient Follow-up data: 1 row per measure per patient

Currently: 183 facilities, 440,000 patients enrolled in care, and 234,000 initiating ART across 5 countries.

AUTOMATED FEEDBACK REPORTS

Webinars: Quarterly web-based interactive meetings to expand knowledge base and ensure best practices among ICAP staff, as well as other interested stakeholders – Clinical:

• Improving effectiveness of adherence in HIV treatment settings• Rapid initiation of ART/ARV during pregnancy• ART for prevention: Evidence from recent studies

– M&E methodology and data dissemination: • Using aggregate data for program M&E• Basic epidemiologic measures of disease occurrence• Using routinely-collected data to estimate patient retention

DataBytes: Periodic bulletin highlighting results from routine data– Characteristics and outcomes among youth enrolled in ICAP care and treatment facilities

STRATEGIES TO ENHANCE DATA DISSEMINATION AND USE FOR

PROGRAM IMPROVEMENT

HEALTH SYSTEMS STRENGTHENING THROUGH

ICAP SUPPORT

Jan-05 Jul-05 Jan-06 Jul-06 Jan-07 Jul-07 Jan-08 Jul-08 Jan-09 Jul-09 Jan-10 Jul-10 Jan-110

10,000

20,000

30,000

40,000

50,000

ART non-ART palliative care

Num

ber o

f hea

lth w

orke

rs

Source: ICAP URS June 2011

CUMULATIVE NUMBER OF HEALTH WORKERS TRAINED IN ART AND NON

ART PALLIATIVE CARE

Source: ICAP PFaCTS Round 5, June 2011.Note: Laboratory services offered: Within the facility: specimen collection and testing done within this facility.At another facility: specimen collection done within this facility and testing conducted at another facility or both specimen collection and testing are conducted at another facility.

AVAILABILITY OF LABORATORY ASSAYS AT FACILITIES WHERE ICAP SUPPORTS CARE

AND TREATMENT (n=594)

Perc

ent o

f fac

ilitie

s

CD4 count Hemoglobin / Hematocrit

Creatinine Hepatitis B sur-face antigen

Liver enzyme test

Infant diagnosis / PCR

Sputum smear for TB

HIV-RNA0%

50%

100%

26%

65%

32%24% 30%

5%

66%

2%

74%

34%

63%

54%59%

95%

29%

40%

1%5%

22%11% 4%

59%

Available within the facility Available at another facility Not available

INCREASING AVAILABILITY OF PATIENT SUPPORT SERVICES AT ICAP SUPPORTED CARE AND TREATMENT CLINICS (N=248*)

Perc

ent w

ith s

ervic

e

Source: ICAP PFaCTS June 2011. Notes: *Only clinics that submitted all three rounds of data collection are included. ART adherence counseling: Verbal patient education provided by trained personnel at least every 3 months. Outreach: patients who miss clinic follow-up or medication pick up visits are identified and contacted by facility personnel. Nutritional treatment for children and infants: treatment and weaning for severely malnourished children / infants. Nutritional treatment for adults: treatment for severely malnourished adults. Food rations for adults or children: provision of snacks, food packets, or other food rations to promote ART adherence or household food security.

ART adherence counseling Outreach Peer educator program Nutritional treatment for adults

Nutritional treatment for in-fants/children

Food rations for adults or children

0%

50%

100%

90%

48%

40%

19%

29%

13%

98%

78%

71%

36%

56%

25%

99%96%

85%

46%

64%

32%

Jan-08 Jul-09 Jul-10

Sep-08 Dec-08 Mar-09 Jun-09 Sep-09 Dec-09 Mar-10 Jun-10 Sep-10 Dec-10 Mar-11 Jun-110%

50%

100%

41%31%

24% 28%19% 16%

22%12% 8% 5% 8% 6%

49%59%

67%63%

71%70%

65%75% 79%

80%80%

68%

10% 10% 10% 8% 9% 13% 13% 13% 13% 16% 12%

16%

0.1055126792

SD-NVP Multi-drug regimens Initiated ART Already on ART*

n= 3,684 n= 5,133 n = 5,778 n= 7,931 n= 7,990 n= 9,070

INCREASED USE OF MULTI DRUG ARV REGIMENS IN ICAP SUPPORTED PMTCT

PROGRAMS

Perc

ent o

f wom

en

Source: ICAP URS June 2011Notes: Multi-drug regimens prior to April 2011 include AZT/sd-NVP, AZT/3TC tail postpartum, and HAART at 34 weeks.*Central data collection of indicator "HIV+ women already on ART" began in April 2011

Jun-08 Sep-08 Dec-08 Mar-09 Jun-09 Sep-09 Dec-09 Mar-10 Jun-10 Sep-10 Dec-10 Mar-11 Jun-110%

20%

40%

60%

80%

100%

0

100

200

300

400

500

600

700

67%62% 65% 62% 65% 68% 68%

72% 73% 75% 72% 74% 77%

Proportion # clinics

GROWING PROPORTION OF NEW HIV CARE PATIENTS SCREENED FOR TB

Perc

ent o

f pat

ient

s

Source: ICAP URS June 2011Note: Côte d’Ivoire began reporting in April-June 2008 quarter and South Africa began in July-September 2008 quarter. Data are only from clinics currently supported and reporting. As of March 2010, new HIV care patients excludes patients who knew their TB status at enrollment.

n=22,289 n=26,984 n=30,440 n=33,311 n=34,834 n=38,432 n=43,525

Number of clinics

New HIV care patients

Sep-07 Dec-07 Mar-08 Jun-08 Sep-08 Dec-08 Mar-09 Jun-09 Sep-09 Dec-09 Mar-10 Jun-10 Sep-10 Dec-10 Mar-11 Jun-110%

50%

100%

0

100

200

300

400

500

600

82%88%

83%89% 90% 91% 93% 94%

86% 86%

100%100%

74%84%

76%85%

Proportion # clinics

PROPORTION OF NEW TB PATIENTS WITH UNKNOWN HIV STATUS AT ICAP

SUPPORTED TB CLINICS TESTED FOR HIV OVER TIME

Perc

ent o

f pat

ient

s

n=6,590 n=7,662 n=10,471 n=10,037 n=12,289 n=6,955 n=10,974 n=15,162 TB patients with unknown

HIV status

Source: ICAP URS June 2011.

HIV TESTING AND COUNSELING SERVICES AT ICAP SUPPORTED FACILITIES

Source: ICAP URS June 2011

Num

ber o

f pat

ient

s

Jun-10 Sep-10 Dec-10 Mar-11 Jun-110

100,000

200,000

300,000

400,000

500,000

600,000

293,836

356,053

484,094

528,815 529,479

23,163(8%)

26,285(7%)

33,169(7%)

40,594(8%)

37,422(7%)

Tested and received results HIV+

Jul-08 Oct-08 Jan-09 Apr-09 Jul-09 Oct-09 Jan-10 Apr-10 Jul-10 Oct-10 Jan-11 Apr-110

20

40

60

80

100

120

140

160

180

200

KenyaMozambiqueRwandaTanzaniaOverall

Num

ber o

f clin

icsINCREASING NUMBER OF CARE

AND TREATMENT CLINICS SUBMITTING DATA TO ICAP-NY PATIENT-LEVEL DATA

WAREHOUSE

Source: ICAP Patient-level Data Warehouse June 2011