i nsights into hiv c are s ervice c omprehensiveness and l aboratory c apacity at icap- supported f...

INSIGHTS INTO HIV CARE SERVICE

COMPREHENSIVENESS AND

LABORATORY CAPACITY AT ICAP-SUPPORTED FACILITIES:

FINDINGS FROM PFACTS 2013Caitlin Madevu-Matson ([email protected])

Charon Gwynn ([email protected])SI-NY

PFACTS• Structured repeated assessment of facilities to

describe the scope, diversity, capacity and comprehensiveness of ICAP-supported programs

• Captures information not available from routine indicators :

– Context: Location, type

– Facility characteristics: Related services, e.g. ANC, MC

– Clinic and lab components: Staffing configuration and training, patient support services, laboratory quality essentials

• Data used for program planning, monitoring and evaluation

– Reports and webinars

– URS

– Analyses with other data sources

PFACTS IMPLEMENTATION

• Assessment tools– Core questions maintained from previous

round, tool revised with clinical and programs units

• Data collection– Assessments completed with health facility

personnel– Questionnaires reviewed by in-country ICAP

clinical and M&E units• Data validated through checks and results

uploaded to URS

Care and Treatment PFaCTS

• 7 rounds, 2007 - 2013

• 80 questions

Laboratory PFaCTS• 2 rounds, 2011 -

2013• 162 questions

CARE & TREATMENT PFACTS

Objectives• Present results

from Care and treatment PFaCTS Round 7

• Describe the comprehensiveness of ICAP-supported programs

OUTLINE

• PFaCTS implementation

• Current characteristics

– Context

– Facility

– Clinic

• Comprehensiveness of HIV Care Service

• Summary

• Implications

DEFINITIONS

Facility

Clinic

COMPLETENESS OF PFACTS REPORTING OVER TIME

Round 1 (2007)

Round 2 (2007)

Round 3 (2008)

Round 4 (2009)

Round 5 (2010)

Round 6 (2011)

Round 7 (2013)

-

200

400

600

800

1,000

1,200

211 227

356

541

687

1,003 1,062

158 202

345

490

665

977 1,017

Facilities supported Facilities assessed

Num

ber o

f fac

ilitie

s

COMPLETENESS OF PFACTS REPORTING OVER TIME

Round 1 (2007)

Round 2 (2007)

Round 3 (2008)

Round 4 (2009)

Round 5 (2010)

Round 6 (2011)

Round 7 (2013)

-

200

400

600

800

1,000

1,200

211 227

356

541

687

1,003 1,062

158 202

345

490

665

977 1,017

Facilities supported Facilities assessed

Num

ber o

f fac

ilitie

s

75%

96%

OUTLINE


• Current characteristics– Context : country, location and type

– Facility : services provided outside the CT clinic

– Clinic : services provided in the CT clinic


• Summary

• Implications

COUNTRIES CONTRIBUTING TO PFACTS ROUND 7

• 96% (1017/1062) of facilities with ICAP-supported care and treatment services completed PFaCTS Round 7

• In country completeness ranged from 79% to 100%

Cote d'Ivoire n=27 DR Congo

n=50

Ethiopia n=312

Kenya n=260

Mozambique

n=77

Swaziland

n=83

Tanzania

n=208

FACILITY LOCATION AND TYPE

Geographic location Type of facility0

20

40

60

80

100

Urban; 16.71583088

Semi-urban; 32.74336283

Rural; 50.54080629

Public primary; 64

Public secondary / ter-tiary; 15

Private/other; 21

Perc

ent o

f fac

ilitie

s, %

AVAILABILITY OF HIV RELATED SERVICES (n=1017)

PITC in any clinic/ward PMTCT in ANC TB treatment0

20

40

60

80

100100 97

88

Perc

ent o

f fac

ilitie

s, %

PMTCT SERVICE VARIATION (N=991)

ART in ANC WHO Option0

20

40

60

80

100

ART in ANC; 64.48

Refer to HIV clinic; 32.8

Refer to other facility, 2.72

Option A; 66

Option B; 3

Option B+; 30

Perc

ent o

f fac

ilitie

s, %

TB SERVICE VARIATION (N=1,017)

IPT Triage of TB suspects TB treatment0

20

40

60

80

100

58.6

72

TB clinic only; 60.18

HIV care clinic only; 20.94

HIV care and TB clinic; 6.59

Perc

ent o

f fac

ilitie

s, %

AVAILABILITY OF KEY PATIENT SUPPORT SERVICES (n=1017)

ART adherence

couns

eling

Male co

ndom provis

ion

Outreach

Nutritiona

l treatm

ent (ch

ildren)

Nutritiona

l treatm

ent (ad

ults)0

20

40

60

80

100 99

8881 79

74

Perc

ent o

f fac

ilitie

s, %

TYPE OF ART ADHERENCE SUPPORT AVAILABLE

Clinic a

ppoin

tmen

t remind

er ca

rds

Hando

uts

Pill box

es or

bliste

r pac

ks

Calend

ars or

chec

klist to

track

ART

Clinic s

creen

s edu

catio

nal vi

deos

0

20

40

60

80

100

82

2824

5 3

Perc

ent o

f fac

ilitie

s, %

OUTREACH ACTIVITIES BY TYPE OF PERSONNEL

Peer educator Clinicians Outreach worker Social worker Other0

20

40

60

80

100

61

42

16

59

Perc

ent o

f fac

ilitie

s, %

SECONDARY PREVENTION SERVICE AVAILABILITY

0

20

40

60

80

100 99

7870

45

Perc

ent o

f fac

ilitie

s, %

OUTLINE



– Context

– Facility

– Clinic


• Summary

• Implications

HIV CARECOMPREHENSIVENE

SSCOMPONENTSQuestions

• Does ICAP support comprehensive HIV care programs?

• Has comprehensiveness of HIV care programs changed over time?

• Is there variability in the changes?

WHO Priority Interventions

1. Enabling people to know their HIV status

VCT / PITC

2. Maximizing the health sector’s response to HIV prevention

Preventing sexual transmission

Interventions for IDU

PMTCT

3. Scaling up HIV/AIDS treatment and care

Preventing and treating illness

Treatment and care for HIV

Lab services for HIV monitoring

WHO Priority Interventions

Comprehensive components from PFaCTS

1. Enabling people to know their HIV status

VCT / PITC PITC on-site

2. Maximizing the health sector’s response to HIV prevention

Preventing sexual transmission

Education on behavior change, STI screening, condoms

Interventions for IDU Screening and education on substance use

PMTCT PMTCT on-site

3. Scaling up HIV/AIDS treatment and care

Preventing and treating illness

Cotrimoxazole and TB

Nutritional counseling

Treatment and care for HIV

Adherence support

Outreach services

Lab services for HIV monitoring CD4 on- or off-site

COMPREHENSIVE SERVICES OVER TIME

2007 n= 245

2008 n= 345

2009 n= 490

2009 n= 666

2011 n= 977

2013 n= 1017

0

20

40

60

80

100

1624

55

69 73 7353

44

29

23 18 2230 26

148 9 41 5 2 1

High (7) Medium (6) Low (3-5) Very low (<3)

Perc

ent o

f fac

ilitie

s, %

COMPREHENSIVE SERVICES OVER TIME, SUBSET

2007 2008 2009 2010 2011 20130

20

40

60

80

100

16

24

55

6973 73

1518

57

94 92 90

All participating facilities (increasing n) Subset of facilities participating in every round (n=93)

Perc

ent o

f fac

ilitie

s, %

COMPREHENSIVE SERVICES OVER TIME, BY FACILITY TYPE

Public Primary Public Secondary/Tertiary Private/Other0

20

40

60

80

100

2007 2008 2009 2010 2011 2013

Perc

ent o

f fac

ilitie

s, %

OUTLINE



– Context

– Facility

– Clinic


• Summary

• Implications

CT SUMMARY (1)

• Overall, ICAP facilities maintained high survey completeness

• High on-site availability of essential HIV care services

• Counseling and testing• PMTCT• TB treatment• ART adherence counseling• Outreach • Nutritional counseling• Secondary prevention

CT SUMMARY (2)

• The comprehensiveness of essential HIV care services at all ICAP-supported facilities increased rapidly in 2009 and seems to have stabilized

• Higher proportion of facilities have comprehensive services in

• Facilities supported by ICAP for longer time

• Public primary and secondary/tertiary compared to private/other

• ICAP-supported facilities provide comprehensive services even though most facilities are rural and public primary facilities

• Scale up and expansion of ICAP support to new areas may mean not all facilities will be equipped to offer comprehensive services

• Combine PFaCTS results with routinely collected program and clinical data

– Confirm if availability of comprehensive services is beneficial for program and patient outcomes

– Advocate for wider implementation of comprehensive service delivery models

IMPLICATIONS FOR HIV CARE AND TREATMENT

Laboratory PFaCTS

Outline

• Rationale & Objectives• General findings• Capacity score• Summary& Implications

Laboratory PFaCTS• Captures information on the scope,

diversity, and capacity of ICAP-supported laboratories

• Provides information on laboratory quality essentials (QEs)– Infrastructure and equipment– Human resources– Quality assurance activities– Facility safety– Supply chain management

• Two rounds of PFaCTS conducted to date (2011 & 2013)

RATIONALE FOR LABORATORY PFACTS

• At the facility level:– Measure capacity and progress toward

accreditation– Gap analysis and development of laboratory

specific improvement plan

• At the program level:– Identify gaps in implementing QEs across

supported labs– Prioritization and strategy development

ICAP’S LABORATORY CAPACITY BUILDING FRAMEWORK

Objective Components

1. Improve Integrated Laboratory Infrastructure

physical infrastructure, equipment and accessories

2. Strengthen laboratory personnel capacity

personnel capacity to provide high-quality diagnostic services

3. Improve Laboratory Quality Management System

quality management systems & lab accreditation

4. Strengthen the laboratory network system

laboratory referral system & EQA schemes

OBJECTIVES

• To summarize findings from Lab PFaCTS 2013

• To compare laboratory capacity between years and by key characteristics

OUTLINE


PEPFAR DEFINITION OF CLINICAL LABORATORY

Laboratory that has the capacity to: Perform testing for the diagnosis of HIV infection with either rapid test, EIA or molecular methods; and

Has dedicated laboratory personnel

Perform clinical laboratory tests in any of the following areas:Hematology - Clinical chemistry - Serology Microbiology - CD4 testing - HIV viral loads

TB diagnostic - Malaria diagnosis - OI diagnosis

LABORATORIES COMPLETING PFACTS 2013

# Supported # Reported % Reported

Ethiopia 295 289 98

Kenya 184 182 99

Tanzania 175 119 68

Mozambique 58 53 91

Cote d'lvoire 10 4 40

DR Congo 8 7 88

All Countries 730 654 90

ICAP SUPPORTED LABORATORIES BY FACILITY TYPE AND COUNTRY

All countries (n=654)

Kenya (n=182)

Tanzania (n=119)

Ethiopia (n=289)

Mozambique (n=53)

Cote d'Ivoire (n=4)

DR Congo (n=7)

0

20

40

60

80

100

7887

6680 77

14

1913

26

18 21

10086

3 1 8 2 2

Primary Secondary Tertiary/reference lab

Perc

ent o

f lab

orat

orie

s, %

TYPE OF SUPPORT PROVIDED BY ICAP

AccreditationConstruction/revnovation

RefurbishmentSafety supplies

Processing suppliesEquipment maintenance

Human resourcesTest kit/regent supply

EQASample transportation

EquipmentSupervision

Documents developmentTraining & mentoring

0 20 40 60 80 100

9

15

18

22

25

33

36

41

53

62

69

69

80

91

Percent of laboratories, %

TYPE OF HIV-RELATED TESTS PERFORMED ONSITE

HIV rapid test AFB Syphilis Hematology CD4 count Clinic chem-istry

CD4 percent0

20

40

60

80

10097

92

83

48

27 26

9

Perc

ent o

f lab

orat

orie

s, %

Light/Fluore

scence

micro

scope

Refrigera

tor

Back u

p gen

erator

Hemotology analy

zer

Clinica

l chem

istry a

nalyz

er

CD4 mac

hine

0

20

40

60

80

100

88

69

42

28 25 22

ESSENTIAL EQUIPMENT FOR HIV CARE

Perc

ent o

f lab

orat

orie

s, %

TYPE OF BIOSAFETY EQUIPMENT

Lab coat Detergents Sharps container

Hand wash sta-

tion

Fire ex-tinguisher

Autoclave Protective glasses

Eye wash station

Biosafety cabinet

0

20

40

60

80

100 9488 86

76

1815 14

11 11

Perc

ent o

f lab

orat

orie

s, %

STAFF TRAINED IN KEY TESTS AND LABORATORY MANGEMENT SKILLS

Quality control

Inventory

Biosafety

AFB

HIV rapid test

Malaria

Hematology

Syphilis

Clinic chemistry

CD4 test

Man

agem

ent s

kills

HIV-

rela

ted

test

ing

0 10 20 30 40 50 60 70 80 90

54

43

35

84

79

77

67

67

65

60

Percent of staff, %

QUALITY ASSURANCE/QUALITY CONTROL FOR HIV RELATED TESTS

HIV rapid test (n=635)

CD4 test (n=175)

Hematology (n=314)

Clinical chemistry test (n=171)

0

20

40

60

80

100100

66

48

70

37

24

14 13

39

47

1723

Internal controlInternal proficiencyExternal proficiency

Perc

ent o

f lab

orat

orie

s, %

OUTLINE


ICAP’S LABORATORY CAPACITY BUILDING FRAMEWORK

Objective Components


physical infrastructure, equipment and accessories


personnel capacity to provide high-quality diagnostic services


quality management systems & lab accreditation

4. Strengthen the laboratory network system

laboratory referral system & EQA schemes

LABORATORY CAPACITY SCOREScore Domain Lab PFaCTS Variables


• HIV related tests• laboratory equipment• biosafety equipment/materials• supply chain management system • supply shortages• data collection & specimen

transportation


• % staff received training on each test


• SOP, Internal controls, internal and external proficiency testing

Total Points = 100

CAPACITY SCORES BY FACILITY TYPE AND LOCATION

All (n=654)

Primary (n=511)

Secondary (n=126)

Tertiary (n=17)

Urban (n=111)

Semi-urban (n=250)

Rural (n=240)

Unknown (n=53)

0

20

40

60

80

100

4845

61 5953

4945 44

Aver

age

capa

city

sco

re

CAPACITY SCORES BY COUNTRY AND YEAR

All countries (n=331)

Cote d'Ivoire (n=3)

DR Congo (n=6)

Ethiopia (n=74)

Kenya (n=125)

Mozambique (n=26)

Tanzania (n=97)

0

20

40

60

80

100

46

63

36

43 45

37

525156 55 56

50

43

5120112013

Aver

age

capa

city

sco

re

*Restricted to laboratories completing both 2011 and 2013 Pfacts rounds.

CAPACITY SCORES BY FACILITY AND LOCATION

*Restricted to laboratories completing both 2011 and 2013 PFaCTs rounds.

Primary (n=212)

Secondary (n=106)

Tertiary lab (n=13)

Urban (n=57)

Semi-urban

(n=113)

Rural (n=132)

Unknown (n=29)

0

20

40

60

80

100

41

5560

4552

4339

45

62 6156 56

4744 2011

2013

Aver

age

capa

city

sco

re

OUTLINE


SUMMARY • ICAP supports a wide range of capacity

building activities in the countries where we work

• Technical support areas identified include QA/QC, human resources and infrastructure

• Capacity at ICAP laboratories

– highest at secondary and tertiary and urban facilities

– increased between 2011 and 2013

IMPLICATIONS

• Laboratory PFaCTS can be used to identify and address technical support area needs

• Use of capacity scoring allows for a comprehensive approach to monitoring capacity from routinely collected PFaCTS data

PFACTS DATA USE

• Analysis of key PFaCTS variables can identify areas for targeted technical assistance as well as achievement of program successes

• Innovative approaches in the use of PFaCTS data help us better understand the programs we support

Where’s the Data?

Acknowledgements

• Country M&E, Laboratory and Clinical Teams

• Bereket Alemayehu, Yingfeng Wu, Suzue Saito, SI Specialists

Thank You

FOR MORE INFORMATION

PFaCTS resources

• To view the questionnaires and reports for all rounds, visit the ICAP Data Dissemination page and select PFaCTS.

• http://icapdatadissemination.wikischolars.columbia.edu/Welcome

• To access more PFaCTS results, log into the URS

• https://urs2.icap.columbia.edu/

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