Program and Facility Characteristics Tracking System (PFaCTS) May 8, 2007 ICAP New York Data dissemination meeting

Outline Provisional data from first quarter of 2008 Proposed procedures for the development and implementation of new multi-country M&E indicators and data collection modules Content area presentation ICAP Program and Facility Characteristics Tracking System

I. Summary of ICAP-supported activities through March 2008 Care and treatment (cumulative) 256 of 284 sites reporting 458,848 patients have been cumulatively enrolled in care since 2004, 213,549 of whom initiated ART. TB screening in HIV patients (last quarter) 188 of 235 sites reporting Of 30,050 newly enrolled patients, 68% were screened for TB at enrollment (compared with 65%, 61%, and 54% in the previous 3 quarters, respectively). PMTCT (last quarter) 322 of 342 sites reporting 51,503 women attending ANC (first visit) were screened for HIV, 7,029 screened positive, and 2,579 received prophylaxis 8,070 PMTCT client partners were tested.  Counseling and testing (last quarter) 198 sites (in 7 countries) providing services 131,540 individuals received counseling and testing for HIV and received their test results

Proposed procedures for the development and implementation of new multi-country M&E indicators and data collection modules

What constitutes a M&E data collection module (DCM)? Any systematically collected indicator information that is collected across all ICAP country programs and facilities and is expected to be reported to ICAP-NY for the purposes of program monitoring and evaluation, program planning or analysis Examples: Quarterly care and treatment indicators PFaCTS

Upcoming new indicators and DCMs New indicators indicators New suites of indicators as part of PEPFAR II New data collection modules Testing and counseling Laboratory service indicators Laboratory PFaCTS

Procedures for Developing new DCMs A brief proposal for new DCMs must be submitted to the Director of the M&E unit Proposal format and workspace page is under development Proposals should include: rationale for collecting the data description of the type of data to be collected summary of the existing infrastructure within ICAP programs to collect the data proposed timeline The ICAP Leadership will approve or reject the proposal for a new DCM If approved, an MER-NY technical lead will be assigned to work with an ICAP-NY content expert and in-country M&E teams to develop an SOP for the DCM The SOP will include: A rationale for the DCM Indicators/variables, definitions and data sources to be used Procedures and roles/responsibilities for capturing data Relevant existing sources of information (e.g., indicators, SOCs, etc) will be reviewed in the DCM SOP development process Draft SOP will be piloted in at least one country; lessons learned will be incorporated in the SOP

Review & Implementation of Approved DCMs The final draft of the DCM SOP will be shared for review and comment with ICAP-NY, Country Directors and relevant staff to discuss the rationale, importance and appropriateness of the DCM Comments and issues on the proposed DCM will be taken, reviewed and resolved in the 2 weeks following the presentation of the DSM Approximately 1 month after the comment period a finalized SOP will be distributed to the countries for implementation The finalized SOP will be distributed to the countries Country M&E teams and other relevant staff will be expected to begin implementing the SOP in the next reporting cycle (depending on the type of DCM) Countries without the necessary infrastructure to implement the DCM will have more time, but will be expected to develop an implementation plan (with help from the M&E Liaison)

Presentation Outline Summary of recently submitted ICAP data PFaCTS background Program planning and implementation with PFaCTS data IV. Description and evaluation with PFaCTS data V. Operational research with PFaCTS VI. PFaCTS on URS

II. PFaCTS Semi-annual facility assessment designed to capture information on: Site characteristics e.g., level of service, location Facility characteristics e.g., number of exam rooms Program characteristics e.g., program components, lab services, patient support Contextual information E.g., background HIV prevalence, urban/rural Staffing information E.g., staff configuration, staff turnover First PFaCTS: January-June 2007

Strengths and limitations of PFaCTS A helpful implementation tool Gets at a wide array of program implementation (e.g., laboratory, patient-support services, context) Measures aspects of implementation (e.g., comprehensiveness) that are not captured by conventional program indicators Describes characteristics of facilities and programs, the contexts in which they operate, and their evolution Structured approach and standard definitions A helpful tool for operations research Limitations Limited depth with regard to information gathered on implementation of complex programmatic activities Accuracy and validity needs assessment and attention May improve with increased use Hard to get standard application of definitions across so many settings

Program and Facility Characteristics Tracking System Uses of PFaCTS: Program planning and implementation: identifying gaps in care and tracking implementation of care and treatment programs Description and evaluation: describe programs and scope of programs, assessing how programs are evolving Evaluation and Operations Research: Examine associations between program, facility, and contextual information and patient outcomes, with both aggregate and patient-level data

treatment facilities supported January-June 2007 July-December 2007 Number of care and treatment facilities supported 255 274 Number of facilities reporting care and treatment data 249 262 Number of facilities completing PFaCTS Round 1: 176 Round 2: 240 Current status Number of facilities completing both PFaCTS 175 Trends

III. Program planning and implementation

Support services available at sites

Laboratory assays available at sites

Staff configuration at sites

Trends in support services available at sites

Trends in laboratory assays available at sites

Trends in staff configuration at sites

IV. Description and Evaluation

Location and type of ICAP-supported HIV care and treatment sites

On-site services by location of HIV care and treatment facility Rural sites N=85 n(%) Urban sites N=154 VCT 85 (100) 154 (100) TB clinic ART pharmacy 59 (69) 137 (89) PMTCT / ANC Labor and delivery 49 (58) 111 (72)

Support services What nutritional support services are being provided to patients at this facility? Please choose all applicable responses. 1 2 3 4 5 6 7 8 9 10 11   12 13 14 Nutritional counseling for adults Nutritional evaluation Infant feeding counseling Multivitamins given to patients Multivitamins & minerals given to patients Vitamin A given to infants Vitamin A given to women postpartum Vitamin A given to other adults or non-infant children Iron given to patients Food support for adults Infant feeding support (including formula, food basket post weaning, provision of other food supplements in support of weaning period) Income generation activities to strengthen food security None Other_____________________

Support services (continued) Is there an outreach program available at the site? 1 2 Yes No Is a peer educator program available? How often do patients at this facility see peer educators? 3 4 5 Once or more a month Once every 1-3 months Once every 4-6 months Less frequently Other ____________________

Support services (continued) What ART adherence support activities are provided at this facility?   Please choose all applicable responses. 1 2 3 4 5 6 7 8 9 10 11 12 Counseling Appointment slips Written/pictorial patient education material Pill boxes or blister packs Calendars, checklists, or other reminders Educational videotapes Alarm clocks, wrist watches, beepers Dedicated ART pharmacist Pharmacist included on multidisciplinary team Routine review of medication pick up None Other______________________

Proportion of ICAP-supported HIV care and treatment sites offering on-site patient support services by number of patients on ART (n=240)

Family-focused care model Which of the following family-focused care service components are provided?   Please choose all applicable responses. 1 2 3 4 5 6 7 8 Querying index patients about family members’ HIV testing status Testing or referral to VCT for adult family members with unknown HIV status Testing or referral to VCT for pediatric family members with unknown HIV status Encouraging enrollment of HIV positive family members into care and treatment Family-centered support groups Recording IDs of family members on patient charts None Other______________________

% of sites offering family-focused care service Proportion of ICAP-supported HIV care and treatment sites offering family-focused care service components (n=240) % of sites offering family-focused care service

Prevention related services What prevention services are available for persons receiving care and treatment at this facility?   Please choose all applicable responses. 1 2 3 4 5 6 7 8 Counseling regarding disclosure to sexual partners Education on sexual behavior changes and safer sex methods Provision of condoms Referral for on-site screening for sexually transmitted infections (STIs) Education on high-risk substance-use behaviors and harm reduction practices Screening for drug and alcohol abuse and when appropriate, referring for substance abuse treatment None Other________________________

% of patients accessing prevention services Proportion of ICAP-supported HIV care and treatment sites with prevention services (n=240) % of patients accessing prevention services

Laboratory services available to the care and treatment program What is the availability and location of CD4 testing for patients at this facility? What is the availability and location of CD4 percent testing for patients at this facility? What is the availability and location of quantitative HIV RNA (viral load) testing for patients at this facility? What is the availability and location of liver function testing for patients at this facility? What is the availability and location of routine blood chemistry testing for patients at this facility? 1 2 3 Available on-site Available off-site Not available

Laboratory services (continued) What is the availability of infant diagnostic testing for patients at this facility? 1 2 3 4 Dried blood smear or venous sampling, and laboratory testing (DNA PCR) available on-site   Dried blood smear or venous sampling available on-site, and laboratory testing (DNA PCR) available off-site Dried blood smear or venous sampling, and laboratory testing (DNA PCR) available off-site Not available

Proportion of ICAP-supported HIV care and treatment sites with access to key HIV-related laboratory assays (n=240) ICAP Average=95% % sites * Key HIV-related laboratory assays include CD4, CD4 percent, HIV-RNA, LFT and blood chemistry.

Staffing Characteristics How many non-pediatrician physicians are currently working in the facility?   Only include medical doctors and not medical assistants, medical officers, or medical technicians. Please exclude pediatricians. Use the table below to note the number of physicians who attend to patients each day in the mornings and in the afternoons. Question repeated for pediatricians, nurses, non-physician clinicians and other staff. S M T W Th F Sa AM PM

Number of full time equivalent providers Number of full time equivalent providers at ICAP-supported HIV care and treatment sites by country and overall (n=240) Number of full time equivalent providers 40

Mean number of ART patients per facility by country and overall, December 2007

Number of providers per 1000 patients on ART Mean number of health care providers per 1000 patients on ART at ICAP-supported HIV care and treatment sites (n=240) Number of providers per 1000 patients on ART

Assessing program evolution

Trend in proportion of ICAP-supported HIV care and treatment sites offering on-site services(n=175)

Trend in proportion of ICAP-supported HIV care and treatment sites offering on-site patient support services (n=175)

Proportion of ICAP-supported HIV care and treatment sites with access to laboratory assays (n=175)

V. Operational research

Are loss to follow-up rates associated with program and facility characteristics? “Identifying Optimal Models of HIV Care Approaches in Sub-Saharan Africa” protocols funded by Doris Duke Charitable Foundation, CDC public health evaluations in Mozambique and South Africa

Availability of support services and lost to follow-up rates   Patient support groups Peer educator program Outreach program Food support for adults Food support for infants Adherence support Prevention services Family planning provision LTF rate * 25 de Setembro Health Center X 358 Akumi Health Center - Nacala 14 Anchilo Health Center 765 Catembe Health Center Chicuque Rural Hospital 9.6 Chokwe Rural Hospital 45 Gurue Rural Hospital 231 * LTF rate = # patients lost to follow-up per 1000 person-years on ART

Through Sept 2007, subset for analysis Lost to follow-up and person-years on ART at ICAP-supported care and treatment sites Through Sept 2007, subset for analysis Number of sites ever reporting N=164 Cumulative number ever on ART 104,412 Cumulative number lost to follow-up 8,573 Cumulative number of known deaths 6,211 Cumulative person-years on ART 81,479 Crude lost to follow-up rate† 105 Crude death rate (known deaths)† 76 Weighted and adjusted lost to follow-up rate†* 125 † Per 1000 person-years; weighted by cumulative ART enrolment and adjusted for country 50

Variability of LTF rates across facilities LTF per 1000 person-years on ART Facility

Variability of LTF rates across and within ICAP supported countries LTF per 1000 person-years on ART

Lost to follow-up rates by availability of food support at ICAP-supported care and treatment sites LTF per 1000 person-years on ART mean=156 mean=134 Food support No food support

LTF rate (multivariate)† Linear regression results LTF rate (multivariate)† Rate Ratio Support services available on-site Adherence support 163* 0.76 (0.58, 0.96) No adherence support (ref) 214 Ref Food support 144* 0.77 (0.62, 0.96) No Food support (ref) 187 Peer support 197 1.2 (0.97, 1.5) No peer support (ref) 164 Outreach program 174 1.1 (0.88, 1.4) No outreach program (ref) 160 ref † per 1000 person-years on ART, weighted by cumulative ART enrolment and adjusted for country; multivariate model also adjusted for type of site, location, age of program, provider to patient ratio * p<.05

Next steps Round 3 of PFaCTS: June 2008 Enhance utilization of PFaCTS data for program tracking and planning Descriptive analysis using PFaCTS data to describe scope of programs and evolution of programs during rapid scale up Operational research: - nutritional support and loss to follow-up - program-level factors and CD4 count at ART initiation - cost-effectiveness analysis to determine cost-effectiveness of support services

Acknowledgements Data collection and management: - MER country teams and site staff - MER-NY Questionnaire development: - ICAP leadership - Desk officers - Country directors - Senior M&E advisors