Presentation Title Presenter(s) Centers for Disease Control and Prevention AIDS Turning the Tide Together

PEPFAR World Health Organization (WHO) Global HIV Drug Resistance (HIVDR) Surveillance In 2006, WHO established global HIV drug resistance surveillance using early warning indicators (EWIs) Eight EWIs were used to monitor factors associated with the emergence of HIVDR Countries conduct EWI surveys and report results annually to WHO

PEPFAR Methods: Overview For this analysis, we analyzed multi-country data reported to WHO in the period Countries selected a representative sample of clinics. Different EWIs were surveyed in different clinics, depending on the availability of data. The total number of clinics meeting the target in countries and regions in each year was summed and presented as a proportion of total clinics surveyed. We selected three EWIs thought to be closely associated with HIVDR.

PEPFAR Methods: Early Warning Indicators EWI-4 monitors antiretroviral drug (ARV) pick-ups on- time. –Target: > 90% of patients picking up ARVs on- time. –This EWI was reported by 25 countries. EWI-6 monitors ARV drug supply continuity and whether stock-outs occur in clinic pharmacies. –Target: 100% of clinic pharmacies with no stock- outs. –This EWI was reported by 32 countries. EWI-8 monitors HIV RNA (virologic) suppression. –Target: > 70% of patients with viral load < 1000 copies/ml at one year ml at one year after starting ARVs. –This EWI was reported by 6 countries.

PEPFAR EWI 4: Percentage of Clinics with On-Time ARV Pick-Ups, by Region and Year Target: > 90% of patients picking up ARVs on-time

PEPFAR EWI 6: Percentage of Clinics with ARV Supply Continuity, by Region and Year Target: 100% of clinic pharmacies with no ARV stock-outs

PEPFAR EWI 8: Percentage of Clinics with Viral Load (VL) Suppression, by Region and Year Target: > 70% of patients with VL suppressed one year post-ARV start

PEPFAR Limitations Many EWI surveys were conducted while patient-level information systems were in development The EWI global surveillance system is young, and still continues to be refined Number of countries reporting on specific EWI varies by year Sample of clinics may vary by country by year May not be same clinics year-to-year in each country

PEPFAR Actions Taken by Countries Following EWI Results Namibia –Migrant workers were seen to be at risk of treatment interruptions –MOHSS has planned an intensification of defaulter tracking systems and improvements in its electronic record system. Malawi –MOH revised electronic medical & pharmacy records to enable abstraction of EWI 4 (on-time ARV pick-ups) China –EWI assessment prompted upgrades to an Internet-based database to routinely monitor EWI at all ART clinics –Results about on-time ARV pick-ups motivated strategies to address programmatic weaknesses

PEPFAR Conclusions Countries across the world are monitoring early warning indicators associated with the emergence of HIVDR EWI results identify “on-time ARV pick-up” as a major challenge for clinics and patients. Methods to improve on-time ARV pick-ups and ARV supply chains should be prioritized by national ARV programs and individual clinics distributing ARVs. National programs have used results to adjust clinic-level information systems and clinic procedures, including adherence counseling and patient-tracking.

PEPFAR Acknowledgements Drs. Anindya De, Drew Baughman, and Yang Liu of Division of Global HIV/AIDS, CDC performed the SAS analyses. Grants from the Bill and Melinda Gates Foundation and from PEPFAR supported EWI surveys in many countries. We acknowledge Ministry of Health staff and local CDC staff in many countries who made these analyses possible.

PEPFAR For more information please contact Centers for Disease Control and Prevention 1600 Clifton Road NE, Atlanta, GA Telephone: CDC-INFO ( )/TTY: Web: The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.