Supporting Sustainable Adherence to HIV Prevention, Care & TreatmentICAP Technical WorkshopOctober 19-22, 2009Kigali, Rwanda

ICAP Adherence Data

Molly McNairy, MD, MSc

To Review

Patients on ART in resource-limited settings can have good immunologic and virologic outcomes

Rates of adherence and barriers to adherence similar across settings

LTFU increases over time (5X higher > 2-3 years)

LTFU relationship with mortality 40-50% of LTFU dead

Rosen 2007, McPherson 2008

Meta-Analysis: Adherence at 2 years

Rosen et al. PLoS 2007 32 studies in SSA 1996-2007 ~75,000 patients in non-research ART 6 mo = 80% pts retained 12 mo = 60% pts retained

At 2 Years*: BEST CASE = 84% WORST CASE = 46% AVERAGE = 61%

~40% LTFU at 2 yearsOf which, LTFU 56%, Death

40%

61% at 24 months

A closer look at ICAP

Adherence Data June 2009URS, PFaCTS, Patient-level

“Those are other programs”

Data Sources

URS data LTFU varies across countries Often means 90 days since last visit

Patient-level data LTFU from care = 12 months since last

clinic LTFU from treatment= 6 months since last

clinic PFACTs

Adherence program characteristics

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

among all patients since enrollment into care (Total 204,000)

WORST CASE SCENARIO:204,000 patients50% at 2 years100,000 patients LTFU?

Application for ICAP Sites

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

among ART patients since ART initiation (Total 91,612 patients)

Pediatric ART patients since ART Initiation Patient level data through June 2009 (n= 28 sites)

0 0.5 1 1.5 250%

55%

60%

65%

70%

75%

80%

85%

90%

95%

100%

ICAP data

20% Default

40% default

Time (years)

# p

ati

ents

on t

reatm

ent

Applying the Meta-Analysis ResultsTo ICAP Adherence Data

*Rosen et al PLoS Med 4 (10) 2007

“Good Adherence>95%”

Our GAP

38504

38869

39234

39600

39965

0

50,000

100,000

150,000

200,000

250,000

300,000

350,000

Reported dead

Lost to follow up

Cumulative initiating ART

ART patients retained in care

Cumulative and current enrollment in ART care

at ICAP-supported HIV care and treatment programs

as of June 2009 (n= 327,092)

Nu

mb

er

of

pati

en

ts

5%

34%

62%

10.3% per

year on ART

Status of ART patients at ICAP sitesJune 2009 (n= 327,092)

*Includes patients who transferred out while on ART.

.59% per year

on ART

5.3% per year

on ART

Lost to Follow-

up

Reported Dead

Stopped ART

Continued ART, 265,251 81%*

Discontinued ART, 61,841

19%

PFaCTS Data on Adherence services

Type of patient support service Type of adherence service # outreach workers Methods for tracking missed appointments Time to follow-up/tracking

Sites offering on-site patient support services (n=323)

% s

ites

wit

h

serv

ice

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%

Take Home: All sites have services, but what are those services doing?

Overall (N =

448)

Cote d'Ivoire

(N =

15)

Ethiopia (N =

49)

Kenya (N =

100)

Lesotho (N

= 31)

Mozambique (N

= 47)

Nigeria (N

= 29)

Rwanda (N =

42)

South Africa (N

= 32)

Swaziland (N

= 25)

Tanzania (N

= 78)

0

20

40

60

80

100

Peer Educator ProgramsPFaCTS round 4 (January-June

2009)

% o

f sit

es

64%

Overall (N = 462)

Cote d'Ivoire (N

= 15)

Ethiopia (N = 50)

Kenya (N = 101)

Lesotho (N = 31)

Mozambique (N = 47)

Nigeria (N

= 29)

Rwanda (N = 46)

South Africa (N

= 32)

Swaziland (N

= 31)

Tanzania (N = 80)

0

20

40

60

80

100

Type of adherence servicesPFaCTS Round 4 (Jan-Jun 2009)

Any Adherence Support Program1Counseling more than once a monthDedicated pharmacist, team pharmacist, and/or routine medication pickup reviewEducational and/or reminder tools2

% o

f site

s

Mean number of outreach workers at ICAP-supported HIV care and treatment sites

(n=183)

Mean n

um

ber

of

outr

each

w

ork

ers

Overa

ll

Moz

ambi

que

South

Afri

ca

Cote

d'Ivo

ire

Tanza

nia

Leso

tho

Ethio

pia

Rwanda

Niger

ia

Zambi

a

Kenya

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

1.4

3.1

2.0

1.51.4 1.4

1.31.1

0.70.5

0.3

Cote d'Ivoire

Ethiopia

KenyaLesotho

Mozambique

NigeriaRwanda

South Africa

Swaziland

Tanzania

Overall

0

5

10

15

20

25

30

35

# o

f o

utr

ea

ch w

ork

ers

/1,0

00

act

ive

A

RT

pa

tie

nts

Siteswith an outreach program

Number of outreach workers per 1,000 active ART patients at ICAP sites with at least 1 dedicated outreach worker,

PFaCTS Round 4 (Jan-Jun 2009)

n=8 n=48 n=18 n=11 n=17 n=39 n=24n=8 n=1 n=33 n=207

Note: The bubbles represent the median across sites and the bars represent the IQR.

Prevention Services Offered at ICAP Sites

92%95%

92%

78%

63%

19%

94% 96%

84%78%

67%

31%

0%

50%

100%

Counseling regarding disclosure

Education on behavior and

safe sex

Provision of condoms

Referral for on-site screening

for STIs

Education on high-risk

substance abuse

Screening for drug and

alcohol abuse

Jul-07 Jul-08

% s

ites

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

Appointment Register (%) Pharmacy Records (%) Database (%)

% o

f s

ite

sMethods of identifying patients with missed ap-

pointments in ICAP-supported care and treatment sites with an outreach program, PFaCTS

round 4 (Jan-Jun 2009)

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 appoint-

mentsPFaCTS round 4 (Jan-Jun 2009)

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%

> 10 days (%) Within 6- 10 days (%) Within 5 days (%)

% o

f site

s

Time between missed appointment and contact attempt for ART patients

PFaCTS Round 4 (Jan-Jun 2009)

Measuring Adherence to Treatment Lack of ICAP structured measurement

tools Difficult to measure

Patient level Lost to treatment program & treatment

interruptions Clinical records Patient self-report, pill count, recall

Surrogate measures Treatment failure Second line regimens

Overall Rwanda South Africa Ethiopia Lesotho Nigeria Mozambique

Kenya Tanzania0%

50%

100%

83%

95% 94%92%

89%

79%

74% 73%

65%

44%

74%

57%

46% 45%

36%34%

39%

27%

43%

69%

44%39%

46%

35%

40%43%

31%

Baseline 6-Month 12-Month

Proportion of patients with CD4 count at baseline, 6, and 12 months after ART initiation

% p

ati

en

ts w

ith

CD

4 c

ou

nt

n=9,921

n=7,420n=13,420 n=25,854

n=10,683

n=9,55

7

n=8,497

n=114,694

n=29,342

Overa

ll

Cote

d'Iv

oire

Ethi

opia

Keny

a

Leso

tho

Moz

ambi

que

Rwan

da

Sout

h Afri

ca

Tanz

ania

-0.3%

0.0%

0.3%

0.6%

0.9%

1.2%

1.5%

All sitesAmong sites with >=1 patients on second line regimens

% A

ctiv

e A

RT

pa

tie

nts

on

se

con

d-l

ine

re

gim

en

sProportion of adult ART patients on second line regimens in

ICAP supported care and treatment sites, June 2009

Note: Restricted to sites that report >=90% of regimen data

LTFU is a complicated term ICAP has LTFU rates similar to other large ARV

programs 40% ART pts LTFU at 2 years (worst case)

Yet, ICAP has >98% of sites reporting adherence programs and multi-level pt support services > 75% sites report counseling more than 1 month,

dedicated adherence pharmacist, and remember/education tools

>85% of sties report having appointment registers > 70% sites report capacity for patient tracking with

phone calls, home visits Average of 6 outreach workers/1000 ART patients

How can we strengthen our adherence support services?

In Summary