Implementation & Impact of HIV Treat All: Big Data, Assessment Trends and Projections Talent Maphosa; MD, MDS, Dip HIV Man Technical Director, OPHID IAS 2017 23rd – 26th July 2017, Paris France 1/17/2019 HIV Treat All _ Zimbabwe Experiences

HIV Treat All _ Zimbabwe Experiences "The message is that there are known knowns - there are things that we know that we know. There are known unknowns - that is to say, there are things that we now know we don't know. But there are also unknown unknowns - there are things we do not know we don't know. And each year we discover a few more of those unknown unknowns.“…Donald Rumsfeld 1/17/2019 HIV Treat All _ Zimbabwe Experiences

Learning Phase Implementation When: June 2016 Where: 6 Learning phase Districts Why: Document key operational and outcome lessons of Treat All implementation to inform guidance in the MOHCC 2016 guidelines. How: created Technical Working Groups coordinated by PEPFAR 1/17/2019 HIV Treat All _ Zimbabwe Experiences

Learning Phase Implementation 6 Learning phase districts: HIV Treat All sensitisation Community mobilization Site-level Clinical Mentorship Quality Improvement Strategic Information & Targeted Assessments 1/17/2019 HIV Treat All _ Zimbabwe Experiences

7 Guiding Learning Phase Questions Acceptability: How acceptable is Treat All among patients, health care workers, health system managers? Site-preparedness: Are health facilities ready to implement Treat All – where are the bottlenecks? ART Initiation: What is impact of Treat All on ART initiation rates? Timing: How does Treat All change timing of ART initiation? Retention: What are 3 and 6 month retention rates among patients initiated on ART under Treat All? Who is getting left behind? Who is failing to link to treatment, retain in care? Implementing experiences: How does Treat All work in practice and how can we optimize? 1/17/2019 HIV Treat All _ Zimbabwe Experiences

HIV Treat All _ Zimbabwe Experiences 1/17/2019 HIV Treat All _ Zimbabwe Experiences

Learning Phase Assessments Assessment Characteristics FACE HIV Routine Program Data When: April 2016 – April 2017 Where: 6 Districts Implementing Treat All Learning Phase Who: 92 Health Facilities What: Monthly monitoring of aggregate facility-level data on HIV testing and ART initiation. Pre & Post Treat All Acceptability & Experiences Survey When: Pre Survey: May 2016; Post Survey: September 2016 Where: Treat All Sensitisation Meeting for Gwanda, Bulilima and Mangwe Districts, Matebeleland South Who: 43 District Health Managers and Health Care Workers What: Standardized questionnaire & focus group discussions. Site Preparedness Survey and Action Planning Tool When: July - September 2016 Where: Bulilima, Mangwe, and Mutare Districts What: Facility-based assessment to identify and problem-solve context-specific bottlenecks that could impede optimal implementation of Treat All. Treat All Inception Cohort Analysis When: July 2016 – March 2017 Where: Bulilima and Mutare Districts Who: 29 health facilities What: Register tracing of cohort of all patients testing HIV positive and initiated on ART in month one of Treat All implementation to determine documented: proportion testing HIV positive initiated on ART, timing to start ART, retention at 3 and 6 months. 1/17/2019 HIV Treat All _ Zimbabwe Experiences

Key Learning Phase Findings Results outline Pre-Acceptability Site-preparedness ART Initiation ART Timing Retention in Care Who is getting left behind? Implementing experiences 1/17/2019 HIV Treat All _ Zimbabwe Experiences

1. Pre-Acceptability Survey Most commonly anticipated barriers to Treat All from health care workers perspective: Staff shortages Increased workload and documentation requirements Reduced time spent with each patient Client refusals to initiate among asymptomatic/high CD4 Adherence and retention problems among clients who start ART early Resources to ensure lifelong ART is available to all clients 1/17/2019 HIV Treat All _ Zimbabwe Experiences

1. Pre-Acceptability Survey High rates of HIV Treat All acceptability observed 92.7% among health care workers 97% among district managers ACCEPTABILITY TAKE HOME: It is important to document and address both pre- conceived benefits and concerns about guideline changes; especially among the implementers as this has the potential to affect performance 1/17/2019 HIV Treat All _ Zimbabwe Experiences

1. Pre-Acceptability: Concerns 1/17/2019 HIV Treat All _ Zimbabwe Experiences

1. Pre-Acceptability: Action Does Treat All mean all clients testing HIV positive should be initiated on the same day as diagnosis? Does pre-ART counselling change with Treat All? What is the minimum standard? Why should ‘healthy clients’ now be initiated on ART when previous guidelines emphasised ART should only be for those ‘clinically eligible’? How do I explain this to clients? 1/17/2019 HIV Treat All _ Zimbabwe Experiences

HIV Treat All _ Zimbabwe Experiences 2. Site Preparedness Common facility bottlenecks: Testing and treatment services offered during limited hours Weak intra and inter-facility linkages from HIV testing to treatment Incomplete documentation of client details/outcomes No Standard Operating Procedures for identifying and tracing clients defaulting from care Shortages and stock-outs of essential commodities (CD4 and VL monitoring) Low Health Care Worker confidence in interpretation and action of viral load results 1/17/2019 HIV Treat All _ Zimbabwe Experiences

2. Site Preparedness Actions Strengthening awareness about emergency order points for ARVs Development of Job Aides: Provider Initiated Testing and Counselling Viral load monitoring Defaulter tracking SOPs Deployment of CRF to improve linkage Differentiated models of care SITE PREPAREDNESS TAKE HOME: To increase HIV treatment coverage through HIV test and treat policies, there is a need to identify and problem solve facility-level bottlenecks esp. linkage to high quality HIV care and treatment 1/17/2019 HIV Treat All _ Zimbabwe Experiences

3. ART Initiation – Aggregate Program Data (90 health facilities) New ART Initiation Abstract MOPED1065 Engelsmann et al, IAS 2017 New HIV diagnosis 8.3% gap 29.4% gap This will provide the structure for the rest of the presentation. 1/17/2019 HIV Treat All _ Zimbabwe Experiences

HIV Treat All _ Zimbabwe Experiences 3. ART Initiation With the introduction of TREAT ALL, Mean ART initiations increased by 130% (p=0.0013) from May to August 2016 5 months after introduction of TREAT ALL, Initiation ratios declined and stabilized at a level 78% higher than pre - TREAT ALL (p=0.0051) Detailed analysis provided in: Oral Abstract TUAD0102 Webb et al & Poster Abstract MOPED1065 Engelsmann et al, IAS 2017 1/17/2019 HIV Treat All _ Zimbabwe Experiences

3. ART Initiation – Inception Cohort Data (29 health facilities) Majority of clients initiated in Month One (N=504): Were female (60.7%; n=306); Median age 35 yrs (IQR: 26- 43yrs). Did NOT have a baseline CD4 count (58.5%; n=295) Did NOT have a Viral Load test (90.1%; n=454) at 6 months Had WHO Clinical Staging done and documented (99.6%; n=502), with 84.5% of them Stage 1 or 2 (n=426) ART INITIATION TAKE HOMES: Removing clinical eligibility results in greater numbers of clients previously ineligible being initiated on treatment. Need to maintain CD4 and VL monitoring as recommended in the guidelines Mini-Oral Abstract 28 Webb et al, INTEREST Workshop 2017. 1/17/2019 HIV Treat All _ Zimbabwe Experiences

HIV Treat All _ Zimbabwe Experiences 3. Monthly trend of ART initiation ratio: Oct 2015 – Jan 2017 (348 health facilities) 1/17/2019 HIV Treat All _ Zimbabwe Experiences

4. ART Timing – Time to Start Approximately 50% of all clients initiated on ART during the 1st month had been diagnosed HIV positive prior to Treat All (n=243; 49.4%). Among those clients diagnosed HIV positive after starting Treat All, 53.4% (n=133; 95%CI: 47.2-59.5) were initiated on ART on the same day as diagnosis. ART TIMING INITIATION TAKE HOME: Treat All has been effective at returning previously ineligible clients to care for ART initiation. Aggregate data indicates Mini-Oral Abstract 28 Webb et al, INTEREST Workshop 2017. 1/17/2019 HIV Treat All _ Zimbabwe Experiences

HIV Treat All _ Zimbabwe Experiences 5. Retention in Care 1/17/2019 HIV Treat All _ Zimbabwe Experiences Mini-Oral Abstract 28 Webb et al, INTEREST Workshop 2017. Documented Retention in Care The majority of clients initiated on ART had evidence of HIV care within first three months (84.5%; n=426). The median time to first care contact after ART initiation was 24 days (IQR: 14-31). Approximately 1/10 clients had no evidence of HIV care after ART initiation (n=50; 9.9%) and were LTFU at the time of data abstraction (Figure 2). 9.9% (n=50; 95%CI:7.6-12.8) of clients had no evidence of care in the past 90 days and 29.6% (n=149; 95%CI:26.0-34.0) missed their last scheduled appointment. Figure. Proportion of clients with evidence of HIV Care following ART Initiation (N=504)

HIV Treat All _ Zimbabwe Experiences 5. Retention in Care ART INITIATION TAKE HOME: Treat All has been effective at returning previously ineligible clients to care for ART initiation However, retention in care needs to be continually monitored especially for clients starting ART on same day of diagnosis. 1/17/2019 HIV Treat All _ Zimbabwe Experiences Documented Retention in Care The majority of clients initiated on ART had evidence of HIV care within first three months (84.5%; n=426). The median time to first care contact after ART initiation was 24 days (IQR: 14-31). Approximately 1/10 clients had no evidence of HIV care after ART initiation (n=50; 9.9%) and were LTFU at the time of data abstraction (Figure 2). 9.9% (n=50; 95%CI:7.6-12.8) of clients had no evidence of care in the past 90 days and 29.6% (n=149; 95%CI:26.0-34.0) missed their last scheduled appointment. Figure. Proportion of clients with evidence of HIV Care following ART Initiation (N=504)

6. Who is getting left behind? As compared to women, men testing HIV positive: Presented at older median [IQR] age 37 [30-43] vs. 31[27-39], A significantly greater proportion of men tested HIV positive while seeking care for other illnesses in outpatient departments (M: 59.2% vs. F: 45.3%; p=0.0003) Had significantly lower ART initiation rates (75% vs. 82%; p=0.05) 1/17/2019 HIV Treat All _ Zimbabwe Experiences Documented Retention in Care The majority of clients initiated on ART had evidence of HIV care within first three months (84.5%; n=426). The median time to first care contact after ART initiation was 24 days (IQR: 14-31). Approximately 1/10 clients had no evidence of HIV care after ART initiation (n=50; 9.9%) and were LTFU at the time of data abstraction (Figure 2). 9.9% (n=50; 95%CI:7.6-12.8) of clients had no evidence of care in the past 90 days and 29.6% (n=149; 95%CI:26.0-34.0) missed their last scheduled appointment. Figure. Proportion of clients with evidence of HIV Care following ART Initiation (N=504)

6. Who is getting left behind? Men: Were less likely to have CD4 taken (M: 45% vs F:54%) Among those with CD4 taken, men had lower median CD4 cell count 186 cell/µL[101-316] vs. 334 cell/µL[186-519] than their female counterparts. Key and vulnerable populations We know they are getting left behind, but data is scarce – the next frontier of Treat All in our context 1/17/2019 HIV Treat All _ Zimbabwe Experiences Documented Retention in Care The majority of clients initiated on ART had evidence of HIV care within first three months (84.5%; n=426). The median time to first care contact after ART initiation was 24 days (IQR: 14-31). Approximately 1/10 clients had no evidence of HIV care after ART initiation (n=50; 9.9%) and were LTFU at the time of data abstraction (Figure 2). 9.9% (n=50; 95%CI:7.6-12.8) of clients had no evidence of care in the past 90 days and 29.6% (n=149; 95%CI:26.0-34.0) missed their last scheduled appointment. Figure. Proportion of clients with evidence of HIV Care following ART Initiation (N=504)

7. Experiences Implementing Treat All Acceptability high among patients Need to drive the benefits of early treatment among those not symptomatic of HIV – working with MOHCC and WHO we developed a Frequently Asked Question pamphlet Zero ARV stock outs reported – emphasis on strengthening Emergency Order Points (EOPs) at District Hospital with stock inventory prior to start of Treat All (Site Preparedness) 1/17/2019 HIV Treat All _ Zimbabwe Experiences

7. Experiences Implementing Treat All Patients expressed “appreciation and gratitude” for ability to receive HIV treatment upon diagnosis Avoids stress of wait with previous eligibility criteria “Patients no longer want to wait to be ill and want to be well informed.” 1/17/2019 HIV Treat All _ Zimbabwe Experiences

HIV Treat All _ Zimbabwe Experiences 8. Next Steps Key lessons learnt were packaged in a ‘Treat All Toolkit’ The toolkit provide tips for optimizing implementation of the OSDM and MOHCC ART Guidelines Retention analysis at 12 months Report of the Treat All learning phase will be disseminated. 1/17/2019 HIV Treat All _ Zimbabwe Experiences

Infant Feeding and HIV _ Zimbabwe experience Acknowledgements 1/17/2019 Infant Feeding and HIV _ Zimbabwe experience