FHI’s Global ART Program: Today's snapshot and tomorrow's vision 10 August 2010 Kwasi Torpey, MD, PhD, MPH Regional Senior Technical Advisor, FHI 8 th Annual Track 1.0 ART Meeting

Part 1: Today’s Snapshot Overview of FHI’s Global ART Program Provision of ART in 14 countries – across Asia, Africa and the Caribbean 322,586 patients currently on ART as of March 2010; of those: – 102,164 (31.7%) are in Zambia – 101,700 (31.5%) are in Nigeria – 23,245 (7.2%) are less than 15 yrs. old 30,091 patients were newly enrolled on ART from Jan 2010 – March 2010 – 2,143 (7.1%) are less than 15 yrs. old

Early Infant Diagnosis (EID): Dried Blood Spot DNA-PCR Currently being implemented in 6 African countries: Zambia, Kenya, Nigeria, Mozambique, Tanzania & Rwanda Over 45,000 children tested through EID – 27,274 in Zambia alone Systems for early delivery of results and integration into under 5 clinics – sms printers – Web2sms for results pick up

Early Infant Diagnosis (EID): Dried Blood Spot DNA-PCR (2) Linking DBS results to determine effectiveness of PMTCT intervention Assessing the role of non drug factors eg. Disclosure, infant feeding, home vs facility to optimize effectiveness and efficiency in the light of limited resources

Part 2: Tomorrow’s Vision The Future of ART programming Health Systems Strengthening platform Integration of HIV services beyond Sexual, Reproductive Health & TB. One target community, many diseases! Long-term tracking of ART patients Sustainability

Overview of FHI’s TB/HIV Services Screening for TB and/or provision of TB treatment for HIV+ patients in 15 countries Integration of TB-HIV services As of March 2010: – 149,808 HIV+ patients were screened for TB in HIV setting – 5,699 HIV+ patients in HIV care/treatment started TB treatment

FHI Kenya’s CVD/HIV Integration Pilot 1.Assess CVD risk factors among: – HIV Counseling & Testing (CT) clients – HIV+ patients in care – HIV+ patients on ART 2.Provide behavioral and biomedical interventions (on site and/or through referral) 3.Document and disseminate lessons learned

Rationale for integration CVD complications in HIV patients Burden of CVD and HIV among developing countries; In Kenya: – HIV prevalence is 7.1%, with 1.5 Million PLWHA, and 390,000 on HAART – NCD contributes to 50% morbidity and 32% mortality (Kenya MOH, 2007) Opportunity to combine lessons learned in CVD &HIV Improve efficiency of health care delivery

Risk of high blood pressure according to HIV status (among CT clients) P-value 0.003

Other findings Elevated blood sugar levels in 2 nd line patients Increased lipids in second line patients High blood pressure related to duration of treatment

Strategies for tracking ART Patients Adherence support workers – Home visits and patient tracking SMS reminders – Web2sms for adherence and loss to follow up – Consent forms HMIS – Smartcare - Zambia 93,233 current ART patients (6,844 >15 yrs. – 7.3%) – Lafiya Management Information System (LAMIS) - Nigeria

Lafiya Management Information System (LAMIS) - Nigeria 60,361 patients being tracked 14 facilities Data included: – Patient history – ART status and drug regimen – TB and DOTS status – Clinical stage – Lab tests & results – Facility and lab setup – Specimen storage – Drug Inventory

Attaining operational sustainability Technical Sustainability Programmatic Sustainability Social Sustainability Financial Sustainability Operatio nal Sustainab ility OVERALL SUSTAINABILITY

District Overall score (%) by quarter Months before graduation Q3 2008Q4 2008Q1 2009Q2 2009Q District G3yr 10mo District GGG2yr 11mo District GGG3yr District 497GGGG3yr 1mo District GGG3yr 10mo District GG3yr 10mo District GG3yr 3mo District GG3yr 4mo District G4yr District G2yr 8mo G = Graduated Average3yr 4mo

Challenges for Sustainability Limited pre-service & in-service exposure to QI concepts Absence of strong QI system within MoH Use of financial incentives to drive QI & graduation activities High HCW turnover rate Financial sustainability