1. From HIV Testing to Treatment: Operations Research to Improve ARV Treatment Programs Treatment Acceleration Program Meeting November 30, 2006 Mark Micek, MD, MPH Health Alliance International University of Washington

2. ARV expansion in Mozambique ~1.7 million HIV-infected ~270,000 need ARVs ~30,000 on ARVs (8/06) –11% of those in need

3. HAI in Mozambique Works exclusively with public sector Provincial/district/facility level support –Sofala and Manica Provinces (27% and 19% HIV+) –Expansion of testing and ARV care sites 23 ARV care sites with ~6,000 on ARVs –OR National level support –Maputo

4. Guro Tambara Chemba Maringue Macossa Sussundenga Machaze Machanga Muanza Cheringoma Chibabava HF Providing HAART (new) 17 (13) PLWHA Registered (%) 36,270 (9) Eligible in HAART (%) 5,250 (9) Children <15 y in HAART (% of those in HAART) 420 (8) HIV Treatment Expansion Plan 2006 2003 2004 2005 2006

5. Guro Tambara Chemba Maringue Macossa Sussundenga Machaze Machanga Muanza Cheringoma Chibabava HF Providing HAART (new) 53 (7) PLWHA Registered (%) 100,490 (25) Eligible in HAART (%) 23,903 (40) Children <15 y in HAART (% of those in HAART) 3,585 (15) HIV Treatment Expansion Plan 2008 2003 2004 2005 2006 2007 2008

6. Testing is first step to entering HIV care system

7. Why patients don’t start HAART: where are patients lost? Step 1 Step 2 Step 3 Step 4

8. Specific problems with targeted HIV testing Targeted HIV testing = aimed at a specific group –High-risk (TB, hospitalized) –Special services available (pMTCT) Problems noted with testing  treatment flow –pMTCT –TB patients

9. How can we improve the efficiency of targeted HIV testing? Changing counseling strategies –Opt-in  Opt-out Operational questions: –Will opt-out  ↑ HIV testing? –Will opt-out  ↑ HIV treatment? –Will opt-out  ↑ HIV prevention? (another talk)

10. Problem 1: Loss of pregnant women Year 2005: Beira (2 sites) and Chimoio (3 sites) –52% of pregnant women tested for HIV (opt-in) –28% of HIV+ arrived at an HIV clinic 68% VCT (difference p<.001)

11. Possible solution: change the testing strategy at pMTCT sites 2005 vs. 2Q 2006: ↑ testing by 535/mo (p<.001) ↑ HIV+ by 96/mo (p<.001) ↑ arrival to HIV clinic by 14/mo (p=.07) Strategy ∆

12. Situation not unique UNICEF 2003: 11 national pMTCT programs –49% of HIV+ women received ARV for pMTCT Kenya (Malonza, AIDS, 2003) –1249/1282 accepted test (97%) –Rapid tests associated with higher proportion receiving results (96% vs. 73%, p<.001) –No difference in receiving ARV for pMTCT (19% vs. 11%, p=.2) Malawi (Manzi, Trop Med Int Health, 2005) –96% accepted test –45% of HIV+ and 34% of babies received SD-NVP –Infant to follow-up 81% by 6-months

13. Need to improve referral Improve counseling? –Activists recruited to follow mothers (planned) Reduce stigma? –Community mobilization –Partner testing Decentralize care services? –pMTCT sites with on-site HIV clinic: ~70% referred –CD4 testing (started in pMTCT sites 7/06) –Clinical services (i.e. HAART)

14. Problem 2: High loss of TB patients 2004-2005, TB sites in Beira city –Few TB patients tested for HIV at local VCT (opt-in) New TB patients enrolled ~ 250/mo TB patients tested for HIV ~20/mo –~8% of estimated TB-HIV patients enrolled into care at HIV clinic* Operational questions: –Will opt-out  ↑ HIV testing? –Will opt-out  ↑ HIV treatment? * Micek, MA, Integrating TB and HIV Care in Mozambique: Lessons from an HIV Clinic in Beira. CORE TB/HIV Case Study, The CORE Group, Washington DC, September 2004.

15. Possible solution: Change testing & care for patients in TB treatment Old system TB patient treated at TB center Referred to VCT center for HIV testing Referred to HIV clinic for: HIV counseling Treatment of OIs CTX proph. HAART If HIV+ Continue at TB clinic for: TB treatment New system TB patient treated at TB center “Opt-out” HIV testing at TB center Rotating VCT counselors TB nurses Referred to HIV clinic for: HIV counseling Treatment of OIs HAART If HIV+ Continue at TB clinic for: HIV counseling TB treatment CTX proph.

16. Initial results Implemented in 6 TB facilities in Beira city, Sep 05 Indicators collected using routine data systems First 7mo (Sep 05 – Mar 06) –1,290 patients tested for HIV ~60% of all TB patients –916 (71%) HIV-positive Additional ~20% already knew status –834 (91%) received CTX proph. –504 (55%) registered at HIV clinic –128 (14%) started HAART 25% of those arriving to the HIV clinic High acceptance from patients, TB staff and VCT counselors

17. How to improve referral? Better counseling? Streamline treatment of TB patients at HIV clinic? Decentralize more HIV services to TB sites? CD4 counts HAART

18. OR Center in Beira, Mozambique Collaboration between MOH, UW, HAI Support OR activities in central Mozambique –Agenda development Involve policy personnel –Technical support Protocol development Study management Analysis of results –Training –IRB review (future)

19. Other examples of OR Improve follow-up at HIV care facilities Evaluate decentralization of HIV services to primary health care –Follow-up –Quality of care Improve HAART adherence –mDOT –Community-based treatment supporters Support human resource development –Expand mid-level provider responsibilities –Plan health worker allocation –Retain health care workers

20. Thank you