From HIV Testing to Treatment:

Operations Research to Improve ARV Treatment Programs

Treatment Acceleration Program MeetingNovember 30, 2006

Mark Micek, MD, MPHHealth Alliance International

University of Washington

ARV expansion in Mozambique

• ~1.7 million HIV-infected

• ~270,000 need ARVs

• ~30,000 on ARVs (8/06)– 11% of those in need

HAI in Mozambique

• Works exclusively with public sector

• Provincial/district/facility level support– Sofala and Manica Provinces (27% and 19% HIV+)– Expansion of testing and ARV care sites

• 23 ARV care sites with ~6,000 on ARVs

– OR

• National level support– Maputo

GuroGuro TambaraTambara

ChembaChemba

MaringueMaringueMacossaMacossa

SussundengaSussundenga

MachazeMachaze

MachangaMachanga

MuanzaMuanza

CheringomaCheringoma

ChibabavaChibabava

HF Providing HAART (new)

17 (13)

PLWHA Registered (%) 36,270 (9)

Eligible in HAART (%) 5,250 (9)

Children <15 y in HAART (% of those in HAART)

420 (8)

HIV Treatment Expansion Plan

2006

2003 2004

2005 2006

GuroGuro TambaraTambara

ChembaChemba

MaringueMaringueMacossaMacossa

SussundengaSussundenga

MachazeMachaze

MachangaMachanga

MuanzaMuanza

CheringomaCheringoma

ChibabavaChibabava

HF Providing HAART (new) 53 (7)

PLWHA Registered (%) 100,490 (25)

Eligible in HAART (%) 23,903 (40)

Children <15 y in HAART (% of those in HAART)

3,585 (15)

HIV Treatment Expansion Plan

2008

2003 2004

2005 2006

2007 2008

Testing is first step to entering HIV care system

HIV testing centers VCT

Home-based Care

Pregnant

Day Hospital Clinical evaluation (CD4)

Start HAART in

eligible patients

Adherence to ARV

Treatment Adherence to

Care

Youth

Community

TB patients

Ill/Hospitalized Hospital

Youth VCT

pMTCT

STEP 1 HIV Testing

STEP 2 Arrival to

Day Hospital

STEP 3 CD4

Testing

STEP 4 Start

HAART

Why patients don’t start HAART: where are patients lost?

Monthly flow through the HIV care system in Beira and Chimoio, Mozambique, Jun 04 - Sept 05

HIV+

Undergo CD4 testing (78%)

Enroll at HIV clinic (59%)

Eligible for HAART (48%)

Start HAART (46%)

0

100

200

300

400

500

600

700

Ave

rag

e p

atie

nts

per

mo

nth

Step 1

Step 2

Step 3

Step 4

Specific problems with targeted HIV testing

• Targeted HIV testing = aimed at a specific group– High-risk (TB, hospitalized)– Special services available (pMTCT)

• Problems noted with testing treatment flow– pMTCT– TB patients

How can we improve the efficiency of targeted HIV testing?

• Changing counseling strategies– Opt-in Opt-out

• Operational questions:– Will opt-out ↑ HIV testing?– Will opt-out ↑ HIV treatment?– Will opt-out ↑ HIV prevention? (another talk)

Problem 1: Loss of pregnant women

• Year 2005: Beira (2 sites) and Chimoio (3 sites)– 52% of pregnant women tested for HIV

(opt-in)– 28% of HIV+ arrived at an HIV clinic

• 68% VCT (difference p<.001)

Possible solution: change the testing strategy at pMTCT sites

2005 vs. 2Q 2006: ↑ testing by 535/mo (p<.001)↑ HIV+ by 96/mo (p<.001)↑ arrival to HIV clinic by 14/mo (p=.07)

Number of pregnant women testing for HIV and arriving at an HIV clinic

0

200

400

600

800

1000

1200

1400

Q1 2005 Q2 2005 Q3 2005 Q4 2005 Q1 2006 Q2 2006

Quarter

Nu

mb

er

of

pre

gn

an

t w

om

en

# Tested for HIV

# HIV-positive

# Arriving at HIVclinic

% of pregnant women testing for HIV and arriving at an HIV clinic

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

Q1 2005 Q2 2005 Q3 2005 Q4 2005 Q1 2006 Q2 2006

Quarter

% o

f p

reg

na

nt

wo

me

n

% Tested for HIV

% Arriving at HIVclinic

Strategy ∆Strategy ∆

Situation not unique

• UNICEF 2003: 11 national pMTCT programs– 49% of HIV+ women received ARV for pMTCT

• Kenya (Malonza, AIDS, 2003)– 1249/1282 accepted test (97%)– Rapid tests associated with higher proportion receiving

results (96% vs. 73%, p<.001)– No difference in receiving ARV for pMTCT (19% vs. 11%,

p=.2)

• Malawi (Manzi, Trop Med Int Health, 2005)– 96% accepted test– 45% of HIV+ and 34% of babies received SD-NVP– Infant to follow-up 81% by 6-months

Need to improve referral

• Improve counseling?– Activists recruited to follow mothers (planned)

• Reduce stigma?– Community mobilization– Partner testing

• Decentralize care services?– pMTCT sites with on-site HIV clinic: ~70% referred– CD4 testing (started in pMTCT sites 7/06)– Clinical services (i.e. HAART)

Problem 2: High loss of TB patients

• 2004-2005, TB sites in Beira city– Few TB patients tested for HIV at local VCT (opt-in)

• New TB patients enrolled ~ 250/mo• TB patients tested for HIV ~20/mo

– ~8% of estimated TB-HIV patients enrolled into care at HIV clinic*

• Operational questions:– Will opt-out ↑ HIV testing?– Will opt-out ↑ HIV treatment?

* Micek, MA, Integrating TB and HIV Care in Mozambique: Lessons from an HIV Clinic in Beira. CORE TB/HIV Case Study, The CORE Group, Washington DC, September 2004.

Possible solution: Change testing & care for patients in TB treatment

Old system

TB patient treated at TB center

Referred to VCT center for HIV testing

Referred to HIV clinic for:

HIV counselingTreatment of OIs

CTX proph.HAART

If HIV+

Continue at TB clinic for: TB treatment

New system

TB patient treated at TB center

“Opt-out” HIV testing at TB centerRotating VCT counselors

TB nurses

Referred to HIV clinic for:

HIV counselingTreatment of OIs

HAART

If HIV+

Continue at TB clinic for:

HIV counselingTB treatmentCTX proph.

Initial results

• Implemented in 6 TB facilities in Beira city, Sep 05

• Indicators collected using routine data systems

• First 7mo (Sep 05 – Mar 06)– 1,290 patients tested for HIV

• ~60% of all TB patients – 916 (71%) HIV-positive

• Additional ~20% already knew status

– 834 (91%) received CTX proph.– 504 (55%) registered at HIV clinic– 128 (14%) started HAART

• 25% of those arriving to the HIV clinic

• High acceptance from patients, TB staff and VCT counselors

How to improve referral?

• Better counseling?

• Streamline treatment of TB patients at HIV clinic?

• Decentralize more HIV services to TB sites?

• CD4 counts• HAART

OR Center in Beira, Mozambique• Collaboration between MOH,

UW, HAI

• Support OR activities in central Mozambique– Agenda development

• Involve policy personnel– Technical support

• Protocol development• Study management• Analysis of results

– Training– IRB review (future)

Other examples of OR

• Improve follow-up at HIV care facilities• Evaluate decentralization of HIV services to

primary health care– Follow-up– Quality of care

• Improve HAART adherence– mDOT– Community-based treatment supporters

• Support human resource development– Expand mid-level provider responsibilities– Plan health worker allocation– Retain health care workers

Thank you