Using m-health strategies to improve laboratory data management in PMTCT programs m-health satellite Washington, July 23, 2012

Financing overview: Malawi is expecting a funding gap in the near term, but significant worsening after 2013, unless additional funding is secured Large numbers of HIV-infected children continue to get infected despite increasing access to PMTCT Access to PMTCT services has expanded markedly in recent years UNAIDS estimates that ~350,000 pediatric HIV infections have been prevented since 1995 But…at best, we are preventing only 20-25% of new infections annually In 2010, there were an estimated 390,000 new pediatric infections More than 1,000 infants are newly infected each day In the absence of treatment, mortality in these infants is very high – approaching 50% by age 2 Source: UA report 2011, Newell et al. Lancet 2005

Financing overview: Malawi is expecting a funding gap in the near term, but significant worsening after 2013, unless additional funding is secured We need to improve performance and strive for “eMTCT”, but we also must do a better job of treating the children already living with HIV 0.1M 0.2M 0.3M 0.4M 0.5M 1.3M 1.9M 2.8M 3.8M 4.9M 6.2M 21% 23% 42% 51% Adults Receiving ART Children Receiving ART Coverage %-Children Coverage %-Adults Adapted from: UA report 2011

Financing overview: Malawi is expecting a funding gap in the near term, but significant worsening after 2013, unless additional funding is secured On the continuum of care for HIV positive mothers and children, infant diagnosis is essential for infant treatment and program monitoring Opt A/B ART HIV Ab test CD4 for ART eligibility Infant Diagnosis ART monitoring in mothers and children Infant diagnosis is essential to monitor progress towards eMTCT and identify infected infants

Financing overview: Malawi is expecting a funding gap in the near term, but significant worsening after 2013, unless additional funding is secured But, infant diagnosis requires virologic testing using DNA-PCR All HIV exposed infants have maternal HIV antibodies so infant diagnosis requires virologic testing DNA PCR identifies the DNA of the virus in cells but requires many steps including extraction, amplification and detection of HIV DNA Use of innovative blood collection methods such as Dried Blood Spots (DBS) has enabled many national programs to offer this test by using sample transport to link peripheral sites to central labs

Financing overview: Malawi is expecting a funding gap in the near term, but significant worsening after 2013, unless additional funding is secured Using DBS and sample transport, in many countries, EID testing has scaled up rapidly in recent years Number of Sites providing EID 145 (29%)285 (44%)550 (58%) Number of sites providing PMTCT Uganda example

Financing overview: Malawi is expecting a funding gap in the near term, but significant worsening after 2013, unless additional funding is secured But scale up of EID has not translated to scale up of infant treatment due to high rates of LTFU – especially between testing and results return Infant Retention Cascade at 3 Regional Referral Hospitals in Uganda Sept 2007 – Feb % of positive infants never received results 35% of positive infants receiving results were never enrolled into care 42% of positive infants in care & treatment were lost Source: CHAI/MOH Uganda 2011

Postnatal PMTCT visits are linked to EPI at 6 and 10 weeks. If the turn around time is too long, EID results are not there when mothers return Kangemi Health Center – Nairobi Total TAT 39 days 14 days 5 days 6 days Batch sent to lab Sample Tested Results Dispatched 18 days DBS drawn for PCR Birth6 wks10 wks Caregiver returns for results 5 days 6 days

GSM Printers were used to reduce turnaround time from availability of result to delivery to clinic 14 days 5 days 6 days Batch sent to lab Sample Tested DBS drawn for PCR Birth6 wks10 wks Caregiver returns for results 5 days 6 days

What’s next after the SMS printers?? An “EID-ecosystem” to leverage the SMS network and build a real time national database of test results A Public-Private partnership between HP, NASCOP and Safaricom resulted in the creation of a real time, online database to track EID nationally EID sample received at lab Sample information entered into data terminal Auto SMS to clinic confirming receipt and providing batch number Information instantly enters NASCOP’s data “cloud” Sample processed and result entered into data terminal Auto SMS sent to clinic with result Paper result dispatched to clinic Safaricom supports the auto SMS function This wireless “ecosystem” enables >2,000 facilities to have access to all data & test results over SMS and web in real time AND allows program staff to review national, regional and site level performance HP provided & supports servers

EID data can be accessed through a web interface

What lessons have we learned, what challenges remain? PPPs work! The support of CHAI, HP and Safaricom has created a highly effective system Building trust with partners was critical. Although it took a while to bring partners on board and overcome concerns of data sharing, the benefits of being able to access and view real time information is apparent to all With transparency comes accountability. Lab performance is closely tracked and problems can be addressed very quickly Clinics and providers are empowered by seeing their performance and having access to this technology The national EID data system helps us track progress better than ever before, but EID is a clinical service not only a programme monitoring tool. When a test is positive it is essential to link that child to treatment and this remains a challenge in many settings