1. Implementation & Impact of HIV Treat All: Big Data, Assessment Trends and Projections
Talent Maphosa; MD, MDS, Dip HIV Man
Technical Director, OPHID
IAS 2017
23rd – 26th July 2017, Paris France
1/17/2019
HIV Treat All _ Zimbabwe Experiences

2. HIV Treat All _ Zimbabwe Experiences
"The message is that there are known knowns - there are things that we know that we know. There are known unknowns - that is to say, there are things that we now know we don't know. But there are also unknown unknowns - there are things we do not know we don't know. And each year we discover a few more of those unknown unknowns.“…Donald Rumsfeld
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HIV Treat All _ Zimbabwe Experiences

3. Learning Phase Implementation
When: June 2016
Where: 6 Learning phase Districts
Why: Document key operational and outcome lessons of Treat All implementation to inform guidance in the MOHCC 2016 guidelines.
How: created Technical Working Groups coordinated by PEPFAR
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HIV Treat All _ Zimbabwe Experiences

4. Learning Phase Implementation
6 Learning phase districts:
HIV Treat All sensitisation
Community mobilization
Site-level Clinical Mentorship
Quality Improvement
Strategic Information & Targeted Assessments
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HIV Treat All _ Zimbabwe Experiences

5. 7 Guiding Learning Phase Questions
Acceptability: How acceptable is Treat All among patients, health care workers, health system managers?
Site-preparedness: Are health facilities ready to implement Treat All – where are the bottlenecks?
ART Initiation: What is impact of Treat All on ART initiation rates?
Timing: How does Treat All change timing of ART initiation?
Retention: What are 3 and 6 month retention rates among patients initiated on ART under Treat All?
Who is getting left behind? Who is failing to link to treatment, retain in care?
Implementing experiences: How does Treat All work in practice and how can we optimize?
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HIV Treat All _ Zimbabwe Experiences

6. HIV Treat All _ Zimbabwe Experiences
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HIV Treat All _ Zimbabwe Experiences

7. Learning Phase Assessments Assessment Characteristics
FACE HIV Routine Program Data
When: April 2016 – April 2017
Where: 6 Districts Implementing Treat All Learning Phase
Who: 92 Health Facilities
What: Monthly monitoring of aggregate facility-level data on HIV testing and ART initiation.
Pre & Post Treat All
Acceptability & Experiences Survey
When: Pre Survey: May 2016; Post Survey: September 2016
Where: Treat All Sensitisation Meeting for Gwanda, Bulilima and Mangwe Districts, Matebeleland South
Who: 43 District Health Managers and Health Care Workers
What: Standardized questionnaire & focus group discussions.
Site Preparedness Survey and Action Planning Tool
When: July - September 2016
Where: Bulilima, Mangwe, and Mutare Districts
What: Facility-based assessment to identify and problem-solve context-specific bottlenecks that could impede optimal implementation of Treat All.
Treat All Inception Cohort Analysis
When: July 2016 – March 2017
Where: Bulilima and Mutare Districts
Who: 29 health facilities
What: Register tracing of cohort of all patients testing HIV positive and initiated on ART in month one of Treat All implementation to determine documented: proportion testing HIV positive initiated on ART, timing to start ART, retention at 3 and 6 months.
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HIV Treat All _ Zimbabwe Experiences

8. Key Learning Phase Findings
Results outline
Pre-Acceptability
Site-preparedness
ART Initiation
ART Timing
Retention in Care
Who is getting left behind?
Implementing experiences
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HIV Treat All _ Zimbabwe Experiences

9. 1. Pre-Acceptability Survey
Most commonly anticipated barriers to Treat All from health care workers perspective:
Staff shortages
Increased workload and documentation requirements
Reduced time spent with each patient
Client refusals to initiate among asymptomatic/high CD4
Adherence and retention problems among clients who start ART early
Resources to ensure lifelong ART is available to all clients
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HIV Treat All _ Zimbabwe Experiences

10. 1. Pre-Acceptability Survey
High rates of HIV Treat All acceptability observed
92.7% among health care workers
97% among district managers
ACCEPTABILITY TAKE HOME: It is important to document and address both pre- conceived benefits and concerns about guideline changes; especially among the implementers as this has the potential to affect performance
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HIV Treat All _ Zimbabwe Experiences

11. 1. Pre-Acceptability: Concerns
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HIV Treat All _ Zimbabwe Experiences

12. 1. Pre-Acceptability: Action
Does Treat All mean all clients testing HIV positive should be initiated on the same day as diagnosis?
Does pre-ART counselling change with Treat All? What is the minimum standard?
Why should ‘healthy clients’ now be initiated on ART when previous guidelines emphasised ART should only be for those ‘clinically eligible’? How do I explain this to clients?
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HIV Treat All _ Zimbabwe Experiences

13. HIV Treat All _ Zimbabwe Experiences
2. Site Preparedness
Common facility bottlenecks:
Testing and treatment services offered during limited hours
Weak intra and inter-facility linkages from HIV testing to treatment
Incomplete documentation of client details/outcomes
No Standard Operating Procedures for identifying and tracing clients defaulting from care
Shortages and stock-outs of essential commodities (CD4 and VL monitoring)
Low Health Care Worker confidence in interpretation and action of viral load results
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HIV Treat All _ Zimbabwe Experiences

14. 2. Site Preparedness Actions
Strengthening awareness about emergency order points for ARVs
Development of Job Aides:
Provider Initiated Testing and Counselling
Viral load monitoring
Defaulter tracking SOPs
Deployment of CRF to improve linkage
Differentiated models of care
SITE PREPAREDNESS TAKE HOME: To increase HIV treatment coverage through HIV test and treat policies, there is a need to identify and problem solve facility-level bottlenecks esp. linkage to high quality HIV care and treatment
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HIV Treat All _ Zimbabwe Experiences

15. 3. ART Initiation – Aggregate Program Data (90 health facilities)
New ART Initiation
Abstract MOPED1065 Engelsmann et al, IAS 2017
New HIV diagnosis
8.3% gap
29.4% gap
This will provide the structure for the rest of the presentation.
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HIV Treat All _ Zimbabwe Experiences

16. HIV Treat All _ Zimbabwe Experiences
3. ART Initiation
With the introduction of TREAT ALL,
Mean ART initiations increased by 130% (p=0.0013) from May to August 2016
5 months after introduction of TREAT ALL,
Initiation ratios declined and stabilized at a level 78% higher than pre - TREAT ALL (p=0.0051)
Detailed analysis provided in: Oral Abstract TUAD0102 Webb et al & Poster Abstract MOPED1065 Engelsmann et al, IAS 2017
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HIV Treat All _ Zimbabwe Experiences

17. 3. ART Initiation – Inception Cohort Data (29 health facilities)
Majority of clients initiated in Month One (N=504):
Were female (60.7%; n=306); Median age 35 yrs (IQR: yrs).
Did NOT have a baseline CD4 count (58.5%; n=295)
Did NOT have a Viral Load test (90.1%; n=454) at 6 months
Had WHO Clinical Staging done and documented (99.6%; n=502), with 84.5% of them Stage 1 or 2 (n=426)
ART INITIATION TAKE HOMES:
Removing clinical eligibility results in greater numbers of clients previously ineligible being initiated on treatment.
Need to maintain CD4 and VL monitoring as recommended in the guidelines
Mini-Oral Abstract 28 Webb et al, INTEREST Workshop 2017.
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HIV Treat All _ Zimbabwe Experiences

18. HIV Treat All _ Zimbabwe Experiences
3. Monthly trend of ART initiation ratio: Oct 2015 – Jan (348 health facilities)
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HIV Treat All _ Zimbabwe Experiences

19. 4. ART Timing – Time to Start
Approximately 50% of all clients initiated on ART during the 1st month had been diagnosed HIV positive prior to Treat All (n=243; 49.4%).
Among those clients diagnosed HIV positive after starting Treat All, 53.4% (n=133; 95%CI: ) were initiated on ART on the same day as diagnosis.
ART TIMING INITIATION TAKE HOME: Treat All has been effective at returning previously ineligible clients to care for ART initiation. Aggregate data indicates
Mini-Oral Abstract 28 Webb et al, INTEREST Workshop 2017.
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HIV Treat All _ Zimbabwe Experiences

20. HIV Treat All _ Zimbabwe Experiences
5. Retention in Care
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HIV Treat All _ Zimbabwe Experiences
Mini-Oral Abstract 28 Webb et al, INTEREST Workshop 2017.
Documented Retention in Care
The majority of clients initiated on ART had evidence of HIV care within first three months (84.5%; n=426).
The median time to first care contact after ART initiation was 24 days (IQR: 14-31).
Approximately 1/10 clients had no evidence of HIV care after ART initiation (n=50; 9.9%) and were LTFU at the time of data abstraction (Figure 2).
9.9% (n=50; 95%CI: ) of clients had no evidence of care in the past 90 days and 29.6% (n=149; 95%CI: ) missed their last scheduled appointment.
Figure. Proportion of clients with evidence of HIV Care following ART Initiation (N=504)

21. HIV Treat All _ Zimbabwe Experiences
5. Retention in Care
ART INITIATION TAKE HOME:
Treat All has been effective at returning previously ineligible clients to care for ART initiation
However, retention in care needs to be continually monitored especially for clients starting ART on same day of diagnosis.
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HIV Treat All _ Zimbabwe Experiences
Documented Retention in Care
The majority of clients initiated on ART had evidence of HIV care within first three months (84.5%; n=426).
The median time to first care contact after ART initiation was 24 days (IQR: 14-31).
Approximately 1/10 clients had no evidence of HIV care after ART initiation (n=50; 9.9%) and were LTFU at the time of data abstraction (Figure 2).
9.9% (n=50; 95%CI: ) of clients had no evidence of care in the past 90 days and 29.6% (n=149; 95%CI: ) missed their last scheduled appointment.
Figure. Proportion of clients with evidence of HIV Care following ART Initiation (N=504)

22. 6. Who is getting left behind?
As compared to women, men testing HIV positive:
Presented at older median [IQR] age 37 [30-43] vs. 31[27-39],
A significantly greater proportion of men tested HIV positive while seeking care for other illnesses in outpatient departments (M: 59.2% vs. F: 45.3%; p=0.0003)
Had significantly lower ART initiation rates (75% vs. 82%; p=0.05)
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HIV Treat All _ Zimbabwe Experiences
Documented Retention in Care
The majority of clients initiated on ART had evidence of HIV care within first three months (84.5%; n=426).
The median time to first care contact after ART initiation was 24 days (IQR: 14-31).
Approximately 1/10 clients had no evidence of HIV care after ART initiation (n=50; 9.9%) and were LTFU at the time of data abstraction (Figure 2).
9.9% (n=50; 95%CI: ) of clients had no evidence of care in the past 90 days and 29.6% (n=149; 95%CI: ) missed their last scheduled appointment.
Figure. Proportion of clients with evidence of HIV Care following ART Initiation (N=504)

23. 6. Who is getting left behind?
Men:
Were less likely to have CD4 taken (M: 45% vs F:54%)
Among those with CD4 taken, men had lower median CD4 cell count 186 cell/µL[ ] vs cell/µL[ ] than their female counterparts.
Key and vulnerable populations
We know they are getting left behind, but data is scarce – the next frontier of Treat All in our context
1/17/2019
HIV Treat All _ Zimbabwe Experiences
Documented Retention in Care
The majority of clients initiated on ART had evidence of HIV care within first three months (84.5%; n=426).
The median time to first care contact after ART initiation was 24 days (IQR: 14-31).
Approximately 1/10 clients had no evidence of HIV care after ART initiation (n=50; 9.9%) and were LTFU at the time of data abstraction (Figure 2).
9.9% (n=50; 95%CI: ) of clients had no evidence of care in the past 90 days and 29.6% (n=149; 95%CI: ) missed their last scheduled appointment.
Figure. Proportion of clients with evidence of HIV Care following ART Initiation (N=504)

24. 7. Experiences Implementing Treat All
Acceptability high among patients
Need to drive the benefits of early treatment among those not symptomatic of HIV – working with MOHCC and WHO we developed a Frequently Asked Question pamphlet
Zero ARV stock outs reported – emphasis on strengthening Emergency Order Points (EOPs) at District Hospital with stock inventory prior to start of Treat All (Site Preparedness)
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HIV Treat All _ Zimbabwe Experiences

25. 7. Experiences Implementing Treat All
Patients expressed “appreciation and gratitude” for ability to receive HIV treatment upon diagnosis
Avoids stress of wait with previous eligibility criteria
“Patients no longer want to wait to be ill and want to be well informed.”
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HIV Treat All _ Zimbabwe Experiences

26. HIV Treat All _ Zimbabwe Experiences
8. Next Steps
Key lessons learnt were packaged in a ‘Treat All Toolkit’
The toolkit provide tips for optimizing implementation of the OSDM and MOHCC ART Guidelines
Retention analysis at 12 months
Report of the Treat All learning phase will be disseminated.
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HIV Treat All _ Zimbabwe Experiences

27. Infant Feeding and HIV _ Zimbabwe experience
Acknowledgements
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Infant Feeding and HIV _ Zimbabwe experience