1. Providing Treatment, Restoring Hope Program Updates Dr. Robb Sheneberger, MD University of Maryland School of Medicine Track 1.0 Implementers Meeting Dar Es Salaam August 4th – 6th 2009

2. Who we are Catholic Relief Services (CRS) University of Maryland School of Medicine – Institute of Human Virology (IHV) Futures Group (FG) Catholic Medical Mission Board (CMMB) IMA World Health (IMA)

3. Key achievements Successful evidence based scale up in resource poor settings as of June 30, 2009  167,000 active ART; 460,000 in care  242 local partners Covering 10 countries (Ethiopia added in Y6) Strengthening care delivery systems for sustainable quality chronic health care Comprehensive prevention programs utilizing biomedical, behavioral, and structural approaches Durable viral outcomes Providing a continuum of care through local partners and with community involvement

4. 95 16 34 19 28 22 3 6 Where Do We Work? 242 Local Partner Treatment Facilities (LPTF)+ 184 satellite sites *

5. Who Do We Work With? 242 sites mostly in underserved areas 62% rural 13% peri-urban 24% urban A majority of non-public sites and mission facilities 27% public and 73% non-public. The proportion between public and non-public sites differs by country Breakdown by level 41% primary 57% secondary 2% tertiary

6. Patient Enrollment as of June 30, 2009 Country# of LPTFTotal Active # of patients on ART (Current) Total # of Patients in Care (cumulative) Guyana37492,083 Haiti62,7237,890 Kenya2832,68978,680 Nigeria3427,49168,283 Rwanda163,4179,141 S. Africa2220,46969,937 Tanzania9527,00489,605 Uganda1923,09267,962 Zambia1928,95966,391 Total242166,593459,972

7. Comprehensive Prevention Biomedical: PMTCT; EID; male circumcision; ART for discordant couples Behavioral: Prevention for Positives; family education and testing; male involvement; standard prevention education & measures Structural: integrated ART services with PMTCT, MCH, TB, STI programs; expanded testing; educating traditional community leaders

8. Transition Achievements Developing sustainable international options South Africa: transitioned over to indigenous organizations Institute for Youth Development SA Southern African Catholic Bishops Conference Zambia: invest in sustainable Zambian workforce Site support through collaboration with Churches Health Association of Zambia (CHAZ) Technical support through collaboration with the MOH, University Teaching Hospital, and University of Zambia Transition plans submitted A variety of different models

9. On Treatment Viral Suppression in Randomly Selected Patients 2006 - 2008 Year200620072008Combined Total Samplen= 863n= 2140n= 3161n= 6164 Number of Countries 3536 Durable Viral Suppression

10. Durability of Initial Regimen Key to Long Term Access, Scalability, and Sustainability of Global ARV Treatment Programs

11. Regimen Choice Treatment Strategy Use Care Delivery System Durability: Key Factors

12. n=1200 n=467 n=465 n=110 n=854 n=153

13. Regimen Choice Treatment Strategy Use Care Delivery System Durability: Key Factors

14. CD4 at ART Start and Active Status in Patients Randomly Sampled Through the Quality Improvement Program 2006 - 2008 CD4 baseline Active LTFU Dropped Out Transferred Deceased Total <50605 71.26 %45 5.30 %36 4.24 %91.06%15418.14%849 50 - 100666 77.17 %47 5.45 %21 2.43 %192.20%11012.75%863 101 - 2001420 86.53 %58 3.53 %31 1.89 %221.34%1106.70%1641 201 - 3501621 89.81 %74 4.10 %26 1.44 %251.39%593.27%1805 >350880 92.34 %31 3.25 %2 0.21 %141.47%262.73%953 total5192 84.96 %255 4.17 %116 1.90 %891.46%4597.51%6111

15. CD4 at ART Start and Active Status in Patients Randomly Sampled Through the Quality Improvement Program 2006 - 2008 CD4 baseline Active LTFU Dropped Out Transferred Deceased Total <50605 71.26 %45 5.30 %36 4.24 %91.06%15418.14%849 50 - 100666 77.17 %47 5.45 %21 2.43 %192.20%11012.75%863 101 - 2001420 86.53 %58 3.53 %31 1.89 %221.34%1106.70%1641 201 - 3501621 89.81 %74 4.10 %26 1.44 %251.39%593.27%1805 >350880 92.34 %31 3.25 %2 0.21 %141.47%262.73%953 total5192 84.96 %255 4.17 %116 1.90 %891.46%4597.51%6111

16. Cumulative Patients TransferredDeceasedLTFUStoppedUnknown 22,879 (7.9%) 18,992 (6.5%) 12,323 (4.2%) 5,632 (1.9%) 4,152 (1.4%) 290,237 58 Month Cumulative: Mortality6.5% + LTFU4.2% + Not documented1.4% _________________________ 12.1% Reasons care ended for patients ever enrolled on ART through June 2009

17. Cumulative Patients TransferredDeceasedLTFUStoppedUnknown 22,879 (7.9%) 18,992 (6.5%) 12,323 (4.2%) 5,632 (1.9%) 4,152 (1.4%) 290,237 58 Month Cumulative: Mortality6.5% 7.5% + LTFU4.2% 4.2% + Not documented1.4% _________________________ 12.1% Reasons care ended for patients ever enrolled on ART through June 2009

18. Regimen Choice Treatment Strategy Use Care Delivery System Durability: Key Factors

19. Assessment of Clinical Care Delivery Approaches: Lost to follow up within first 12 months of AIDSRelief at 34 year one sites Tier I Adherence Counseling only Prior to Starting ART n=11 sites Tier II Adherence counseling plus a structured treatment preparation plan n=4 sites Tier III Tier I plus Tier II plus home visits conducted by non medical staff and/or volunteers n=10 sites Tier IV Tier III plus community health nurses supervising Tier III staff & supporting patients at home. n=9 sites

20. Enhancing Active Retention of Patients on ARV Therapy by Linking Clinical Data Management to Real Time Community Support Activities

21. Improving Best Practices with a Goal Keeping people in care Keeping people alive Durable viral suppression

22. Regimen Choice Treatment Strategy Use Care Delivery System Durability of Initial ART Regimen: Key Factors

23. Thank You