icap-columbia university track 1.0 program (mcap) track 1.0 meeting - maputo august 2010
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ICAP-Columbia University Track 1.0 Program (MCAP) Track 1.0 Meeting - Maputo August 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 - PowerPoint PPT PresentationTRANSCRIPT
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