BIPAI Network Experience with multi-month prescribing/refills (MMP) All BIPAI sites provide MMP Broad collective experience with implementation and monitoring of MMP All sites start patients on monthly ART; move to MMP when patients are clinically stable and have good adherence Sites include Lesotho, Swaziland, Uganda, Botswana, Malawi, Tanzania Sites have started MMP as early as 2006 (Malawi) which translates to over 10 years of experience with MMP in children All the national policies and BIPAI practices call for starting patients on monthly ART prescriptions, moving to MMP if they are deemed to be stable clinically (improving CD4 count, undetectable VL and minimal HIV associated morbidity) and have good adherence, after approximately 6 to 9 months of monthly prescriptions. Thereafter, they are monitored and can be returned to monthly prescriptions if their adherence rates deteriorate. In Tanzanian SPEEDI model, patient seen every 2 weeks for 1st month, then monthly until 6 months when assessed for 2-3 month MMP Time savings example: For the age group 0 to 10 years, there were 677 monthly prescription patients, who attended the clinic, in total, 22,807 times between December 1st. 2005 and June 30th. 2016, the average time in days between visits being 32 days. Over the same period there were 1,018 MMP patients, who visited 18,428 times at an average interval of 58 days. This corresponds to a saving of approximately 14,740 visits. A separate analysis conducted by the COE in Swaziland in 2015 demonstrated that the average time spent by each patient at the clinic was 2.05 hours, depending on the number of services accessed and the daily patient load. The number of services accessed was not obviously different between new, predominately monthly prescription patients, and MMP patients. Therefore, implementing MMP does indeed result in significant savings for clinic personnel and possibly also for patients, in that the higher the patient load on any particular day, the longer the patients spend overall in the clinic. The Baylor International Pediatric AIDS Initiative Experience with Multi-Month Prescribing of Anti-retroviral Medication. Wanless, S. 2016.

Standardized Pediatric Expedited Encounters for ART Drugs Initiative (SPEEDI) The SPEEDI program was implemented in January 2013 in the SHZ COE in response to high patient volumes as a means to decongest the clinic while maintaining high quality services.

SPEEDI Outcomes January 2013-December 2015: 1164 utilized SPEEDI Good outcomes (active in care or transferred out): 98.7% Poor outcomes (died or LTFU): 1.2% Mortality of SPEEDI cohort: 0.22 deaths/100 patient years (COE cohort prior to SPEEDI 2.0 deaths/100 patient years) Estimated 291 work hours saved through the program COE patients on ART between 1st March 2011 (when the COE opened) and 31 December 2012 (before the SPEEDI program started) were used as a comparison group. We estimated that a SPEEDI visit saves a physician approximately 5 minutes per patient compared to a routine ART visit. Thus, over the first the three years we piloted SPEEDI visit, it is estimated that the 3493 SPEEDI visits helped save clinicians approximately 291 work hours through implementation of this program Bacha, J. Standardized Pediatric Expedited Encounters for ART Drugs Initiative (SPEEDI): Description and Evaluation of an Innovative Pediatric ART Health Service Delivery Model in Tanzania, 2016.

ART dosing adjustment intervals for children based on WHO median growth curves 25-34.9 kg 20-24.9 kg Weight-based ART dosing bands Boys curve Girls curve Weight (kg) 14-19.9 kg 10-13.9 kg 6-9.9 kg X-axis shoes age: for children <24 months age is displayed in months- for children 2-10 age is in years. Y-axis is body weight. Plotted in red is the growth curve for a boy of average weight by age. The colored bands corresponded to the WHO weight bands used for weight band dosing. Every time the red line crosses into another color band a new ARV dose would be needed- for a boy of average weight this would occur at about 3 months, 15 months, 3 years, almost 6, around 8. These are actually quite long periods of time. While an HIV-infected child is likely to be smaller when identified if treated and suppressed the child will continue to grow with the same trajectory on their own curve. What this means is that while they may not be on the same drug dose as pictured here the intervals between dosing increases will be about the same. There are other factors at play in many of the LMI countries where we work – such as food insecurity or other illnesses, but the overall point of this graph is that dosing increases are actually pretty infrequent, especially after the first 6 months, thus frequency of dosing changes does not need to be a main limitation in implementing multimonth prescribing or alternate service delivery models for children. 3-5.9 kg Approximate age when new ART dose is needed 3 months 15 months 3 years 6 years 8 years Age (in months for ≤24 months; in years for 2-10 years)