1. 2Ministry of Health and Child Care, AIDS & TB Unit, Harare, Zimbabwe
Pre-ART peak and plateau: Early lessons from Zimbabwe on operational impact of "pre-ART mop-up" on ART initiation rates under Treat All
Karen Webb1, Vivian Chitiyo1, Paul Nesara1, Sara Page-Mtongwiza1, Joseph Murungu2, Talent Maphosa1, Patricia Mbetu1, Barbara Engelsmann1
1Organization for Public Health Interventions and Development, Harare, Zimbabwe
2Ministry of Health and Child Care, AIDS & TB Unit, Harare, Zimbabwe
Session TUAD01
Treat All: How to Make It Happen and Can We Afford It?
Tuesday, 25 July, 14:30-16:00

2. BACKGROUND Adult HIV prevalence: 14.6%1
FACE HIV Program: health facilities, 24 Districts
Treat All Learning Phase: June 2016; 8 Districts
Learning Phase Goal: document key operational and outcome lessons to inform guidance in the MOHCC 2016 guidelines.
‘Pre-ART Mop Up’: return of previously ineligible clients to care for ART initiation
1MOHCC, ZIMPHIA 2015–2016.

3. Pre-ART Mop Up Activities
BACKGROUND
Pre-ART Mop Up Activities
Community Awareness and Demand: Roadshows, patient education materials, advocacy
Treat All health system sensitisations: Cascaded from Provincial – District – Facility
Health register review: Identify HIV positive, previously ineligible for ART
Facility support to return clients to care:
Clinical mentorship
Human Resources for Health – Clinic Referral Facilitators
$10/month airtime & log book
Community sensitisation during Treat All Roadshow

4. OBJECTIVE
Primary objective: Establish the proportion of patients initiated on ART from ‘Pre-ART mop up’ following implementation of Treat All.
Secondary objectives:
What influence does Treat All have upon ART initiation rate increases?
Who are the clients that return to care?
Operational experiences and lessons – what worked, what didn’t, how do we get better?

5. METHODS Mixed method programmatic assessments
92 purposively selected PEPFAR-prioritised health facilities; 7 Districts
Routinely reported aggregate facility-level data April-December 2016: new HIV diagnoses, new ART initiations
Cohort analysis of patients newly initiated on ART Treat All Month 1 (June 2016): Retrospective register tracing at 29 health facilities in 2 inception Districts.
Health care worker experiences conducting Pre-ART Mop Up: Follow up to Site Preparedness & Experience Surveys at 92 facilities

6. RESULTS: Aggregate (1) Over the period of interest:
9,265 newly diagnosed HIV positive
9,875 initiated on ART
Following start of Treat All:
The mean number of ART initiations increased sharply, by 130% (p=0.0013) from May to August 2016.

7. RESULTS
Wait, haven’t we seen this before?...

8. RESULTS: Aggregate (2) Pre-Treat All
Proportion ART initiated to diagnosed was 69.4% - well below facility 2nd 90.
Proportion of new ART initiations to newly diagnosed peaked at 160% 2 months after start of Treat All.
Post-Treat All :
Mop up crossover under Treat All learning phase was observed at Month 6
Plateau occurred at rates significantly higher than Pre-Treat All (p<0.0001)

9. RESULTS: Cohort (1)
Patients ART initiated M1 of Treat All; 29 facilities in 2 inception Districts (N=504):
55.2% (n=278; 95%CI: 50-59%) ART initiated after new HIV diagnoses
47.8% (n=133; 95%CI: 42-54%) of these on same day as diagnosis
44.8% (n=226; 95%CI: 41-49%) ART initiated following return to care
Characteristics of those initiated through Pre-ART Mop Up (n=226), majority:
Female (65%; n=147)
Median age 36 years (IQR: years)
Median days from diagnosis to initiation: 398 (IQR: )

10. RESULTS: Cohort (2)
Table. Descriptive characteristics Pre-ART and Newly Diagnosed (N=504)

11. RESULTS: Implementation Experiences
What Worked:
Community mobilisation and awareness activities seen as essential for generating demand during Pre-ART Mop Up.
Systems to keep track of clients successfully returned to care
Success of call backs vs. messages for return to care
“Patients no longer want to wait to be ill [to start treatment] and want to be well informed.”
- Health Care Worker, Bulilima
Health care worker perceptions about positive patient feedback
Challenges:
Completeness and accuracy of paper-based registers
Extra human resources required for follow-up of large groups of patients – seconded OI/ART nurses and primary care counsellors
System and efficiency bottlenecks pre-Treat All persist

12. Limitations
6 month Learning Phase Program Assessment using routine data
Purposive site selection
Difficulty in establishing the baseline Pre-ART population (ideal start to cascade & comparisons)
Availability, accuracy and completeness of registers*Hawthorne effect of implementation assessments & research on practice
Key implementation research questions moving forward:
Who has been left behind? Establishing our baseline Pre-ART cohort.
How many Pre-ART clients were re-initiating after a period of disengagement?
Patient preferences and perspectives for ART preparedness & retention
Implementation research on effective and efficient differentiated models & strategies
Longitudinal follow up to determine retention & VL suppression

13. Conclusion
Treat All increases ART initiations substantially – but not overwhelmingly
Returning pre-ART clients to care is possible, but requires additional resources and systems support in resource constrained settings
After approximately 6 months, the Pre-ART Mop up plateaued – a return to care threshold?
ART initiation rates to new diagnosis remain significantly higher than before Treat All & within the facility-based 2nd 90
Learning phase as pragmatic spring board for program improvements & identifying further operational and implementation research questions

14. ACKNOWLEDGEMENTS
Zimbabwean Ministry of Health and Child Care, AIDS & TB Unit
Provincial Medical Directorate, District Health Executive, Community Leadership, Health Care Workers and PLHIV: Bulilima, Chipinge, Gwanda, Makoni, Mutare, Mutasa & Mangwe Districts
President’s Emergency Plan for AIDS Relief (PEPFAR) through USAID and Families and Communities for Elimination of HIV in Zimbabwe (AID-613-A , FACE HIV)