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 – 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 Number of sites Note: Some sites offer more than one activity

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 dIvoire 652 facilities 861,280 ever enrolled in care Number of patients Number of facilities 430,876 ever initiated ART Swaziland

Cumulative enrollment in HIV care and treatment at sites currently supported by MCAP (Track 1.0) Ethiopia Rwanda S. Africa Tanzania Mozambique Nigeria, Kenya Cote dIvoire 488 facilities 683,838 ever enrolled in care Number of patients Number of facilities 334,157 ever initiated ART

Continued increase in numbers of new enrollees in HIV care and treatment per quarter Number of new patients Note: *New enrollment includes transfers

In each country, new ART enrollment rates are stable (site number constant) Number of new ART patients

Increasing number of children enrolled in HIV care and treatment Ethiopia Lesotho Rwanda S. Africa Tanzania Mozambique Nigeria, Zambia Kenya Cote dIvoire 652 facilities 73,367 ever enrolled in care Number of patients Number of facilities 36,700 ever initiated ART Swaziland

Increasing proportion of new TB patients with unknown HIV status tested for HIV Percent of patients n=5,992 n=6,397 n=8,416 n=8,750 n=8,907 n=10,003 n=7,613 TB patients with unknown HIV status

Increasing proportion of new patient enrolled in HIV care screened for TB Percent of patients n=22,037 New 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 Number of clients

Aiming for Universal Access will require continued scale-up and innovation

ART coverage of estimated PLHIV eligible for treatment-- Central Province, Kenya

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/µL cells/µL 350 cells/µL Missing Total Most recent WHO Stage IV , %0.6%0.9%1.8%4.8% III 3,0802,2853,3983,08411, %6.1%9.1%8.3%31.8% II 1,7711,7283,0791,9878, %4.6%8.3%5.3%23.0% I 1,4011,8974,4162,93610, %5.1%11.9%7.9%28.7% Missing ,1852,0474, %1.3%3.2%5.5%11.6% Total 7,4046,64312,40710,72437, %17.9%33.4%28.8%100.0% Most recent CD4 count <200 cells/µL cells/µL 350 cells/µL Missing Total Most recent WHO Stage IV , %0.6%0.9%1.8%4.8% III 3,0802,2853,3983,08411, %6.1%9.1%8.3%31.8% II 1,7711,7283,0791,9878, %4.6%8.3%5.3%23.0% I 1,4011,8974,4162,93610, %5.1%11.9%7.9%28.7% Missing ,1852,0474, %1.3%3.2%5.5%11.6% Total 7,4046,64312,40710,72437, %17.9%33.4%28.8%100.0% 11,209 (30%) of 37,178 patients started ART during follow-up

Continued need to reach more children Percent pediatric patients on ART n=39,385 n=24,016 n=87,191 n=50,911 n=71,608 n=28,387 n=334,157 n=4,062 n=28,597

Decrease in use of SD-NVP at ICAP-supported PMTCT programs but need to expand ART use, Percent (%) of HIV+ Pregnant Women Multi-drug ARV prophylaxis sdNVP ART

Pregnant women as a proportion of all women initiating ART Percent of women

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 ICAP ART Pt-Level Data, , 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 eligible Pre-ART ost-to-follow-up: Lost-to-follow-up: Death, Stopped care, Transfer, Unknown

ICAP Focus on Retention Dx Pre-ART ART ART in-eligible ART eligible HIV Care and Treatment CHRONIC CARE

Retention across the continuum of HIV diagnosis, care and ART Dx ART ART in-eligible ART eligible Pre-ART ost-to-follow-up: 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

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 ) Number of patients

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-up 9, and loss to program 8 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) % sites with service

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 Indicators Routinely Reported IndicatorData Source DQA 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 sampleClinical 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 sampleClinical 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