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IAS 2013: 7 th IAS Conference on HIV Pathogenesis, Treatment and Prevention. Track D: Operational and Implementation Research . Track D Rapporteur Team. Elvin Geng (UCSF) Thomas Odeny (Kenya Medical Research Institute and University of Washington) Nancy Czaicki (UC Berkeley) - PowerPoint PPT Presentation
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www.ias2013.org Kuala Lumpur, Malaysia , 30 June - 3 July 2013
IAS 2013: 7th IAS Conference on HIV
Pathogenesis, Treatment and Prevention
Track D: Operational and Implementation Research
www.ias2013.org Kuala Lumpur, Malaysia , 30 June - 3 July 2013
Track D Rapporteur Team
• Elvin Geng (UCSF)• Thomas Odeny (Kenya Medical Research
Institute and University of Washington)• Nancy Czaicki (UC Berkeley)• Sathish Kumar (SAATHII)
www.ias2013.org Kuala Lumpur, Malaysia , 30 June - 3 July 2013
Track D: Implementation Science and Operational Research
Evidence Real-worldPractice
Stakeholders (government, NGO’s, civil society)
Health Delivery Organizations (clinics, hospitals, etc)
Individuals (patients, health workers, community)
www.ias2013.org Kuala Lumpur, Malaysia , 30 June - 3 July 2013
Updates on the “Gap”WHO Global Update on HIV Treatment
• 2013 WHO Update on Treatment (Weiler, SUSA02)– 68% adult ART coverage (range 30%-90%)– 70% retention at 3 year– 65% PMTCT coverage (13%-95%)– 34% coverage for children
• WHO Consolidated Guidelines 2013 (SUSA03)– Testing– Adherence– Integration– Decentralization– Task shifting
www.ias2013.org Kuala Lumpur, Malaysia , 30 June - 3 July 2013
2013 IAS Track D Overview: Major Themes
• Important scientific presentations– Adult Treatment Cascade: Linkage and Retention– Voluntary Male Medical Circumcision– Prevention of Mother to Child Transmission– Innovative Delivery Strategies– Point of Care Diagnostics– Quality of Care
• Much more important data at IAS 2013 not captured in this summary!
www.ias2013.org Kuala Lumpur, Malaysia , 30 June - 3 July 2013
Linkage and Retention: Connecting the Dots (MOAD01)
• Linkage after home based testing in South Africa (R. Naik)– Cohort study of 492 patients in Umzimkhulu– 62% linked to care within 3 months– Younger age, alcohol and negative beleifs / denial predicted
failure to link• Linkage after inpatient provider initiatied testing (Dalsone
Kwarisiima)– Patients in Kampala - 70% located by phone after PITC– Among 500 contact - linkage was 91%– Single marital status and younger age associated with non-
linkage
www.ias2013.org Kuala Lumpur, Malaysia , 30 June - 3 July 2013
Linkage and Retention: Connecting the Dots with Social Support (MOAD01)
• Malawi “teen clubs” (Agarwal) – Weekends meetings with fun activities, adherence
support, health education– 192 participants had 3-fold lower rate of loss to follow up
than 750 not in the club • Self help groups in Mozambique (Pestilli)
– In remote and rural Cabo Delgado– 140 patients in self help groups vs. 778 not in groups had
lower loss to follow up (1 vs. 14%)
www.ias2013.org Kuala Lumpur, Malaysia , 30 June - 3 July 2013
Linkage and Retention: Connecting the Dots with mHealth (WELBD02)
• Text messages to improve retention (D. Joseph-Davey)– Three clinics in Maputo, Mozambique Province (two urban,
one rural)– Randomized to SMS reminder before upcoming appointent – 1,106 interviewed and (69%) 830 patients enrolled but 31%
excluded mostly becuase of lacked phone or illiterate• Outcome: Loss-to-follow-up
– All patients difference not signficant– Urban patients (RR=0.56, 0.319-0.969)– Newly urban patients (RR=0.30, 0.105-0.866)
www.ias2013.org Kuala Lumpur, Malaysia , 30 June - 3 July 2013
Urban, recent ART initiated (< 3 months)
Accumulated risk among urban patients
Linkage and Retention: Connecting the Dots with mHealth
(Joseph Davey, WELBD02)
www.ias2013.org Kuala Lumpur, Malaysia , 30 June - 3 July 2013
Circumcision: Getting it Done (MOPDD01)
• Quality during scale-up (Reich)– Evaluation during rapid 15 to 40 VMMC sites from 2011 to
2012 in South Africa – Used WHO instrument for assessing quality – Mean score decreased from 1.68, to 1.51 and then to 1.36
• Outcomes among the lost after surgery (Grund)– In Nyanza – 70% were lost after surgical circumcision– 86% of the lost were located at home– The adverse event rate was 7.5% in those who did not come
vs. 3.3% who did
www.ias2013.org Kuala Lumpur, Malaysia , 30 June - 3 July 2013
PMTCT: Advancing the Cascade and Option B+ (WELBD01)
• Monitoring outcomes of B+ in Malawi (late breaker, Tenthani)
• Cohort of 28,428 women using B+– 17% of all Option B+ patients were LTF six months after
ART initiation. – 37% of sites had less than 10% LTF – 33% of the sites had LTF >20%– LTF was higher in urban, larger sites with EMRS, in sites
operated by the Ministry of Health, and in central hospitals.
www.ias2013.org Kuala Lumpur, Malaysia , 30 June - 3 July 2013
PMTCT Advancing the Cascade: Identifying Bottlenecks in Early Infant Diagnosis (MOAD02)
Result to caregiver- infant ART
Health Facility -result to caregiver
District lab -result to health facility
Central lab -result to district lab
District lab -central lab
Specimen-district lab
0 5 10 15 20 25 30 35 40
Number of DaysHighlands LowlandsFoothills
(Tiam et al)
www.ias2013.org Kuala Lumpur, Malaysia , 30 June - 3 July 2013
PMTCT: Advancing the Cascade (MAOD02)
• Food Insecurity and PMCTC (McCoy)– Rural Zimbabwe probability sample of 8,662
women – 2,841 (32.8%) were food insecure and 1518
(17.5%) had hunger. – 94.7% of women attended antenatal care– Food insecure women with hunger were 42%
more likely to never have attended ANC compared with food secure women
www.ias2013.org Kuala Lumpur, Malaysia , 30 June - 3 July 2013
PMTCT: Advancing the Cascade with Integration (MAOD02)
• Integrating HIV care into ANC (Cohen)– Kisumu, Kenya– Cluster-randomized 16 ANC sites: Co-located HIV care
vs. referral to HIV care among pregnant women newly testing + for HIV
– 1,172 women randomized– Integrated arm had increased HAART initiation (HR =
2.74) and adherence to ARV’s (OR = 4.05)– No significant difference in MTCT, maternal health
outcomes, or HIV-free survival of babies
www.ias2013.org Kuala Lumpur, Malaysia , 30 June - 3 July 2013
PMTCT: SMS Messages to Advance the Cascade
• Randomized trial of SMS messages to 388 pregnant women in Kisumu, Kenya (Odeny)
• Content developed by the patients themselves
www.ias2013.org Kuala Lumpur, Malaysia , 30 June - 3 July 2013
Delivery Strategies: Testing and Community Norms (TUSS01)
• Project Accept: community randomized trail in Thailand, South Africa, Tanzania and Zimbabwe
• Multi-sector community mobilization, mobile VCT, post testing support
• Increase in HIV testing in intervention communities by 25% overall and 45% among men
• Multiple sexual partners among HIV positive men lower by 29% (p = 0.0006)
• Subgroup of In women 25-34, HIV incidence declined (RR=0.7, 0.5-0.9)
•
www.ias2013.org Kuala Lumpur, Malaysia , 30 June - 3 July 2013
Delivery Strategies: Leveraging Social Networks to Test Key Populations (TUAD01)
• Testing strategies to reach key populations of MSM in Nigeria (Adebajo)
• 2009-2012 in 3 states Strategy Numbers testedOpinion leaders refer to facility-based testing 1,988 (6.3%)
Opinion leaders refer to mobile testing 14,726 (46.6%)
Opinion leaders and peers test 14,895 (47.1%)
www.ias2013.org Kuala Lumpur, Malaysia , 30 June - 3 July 2013
Delivery Strategies: HIV Testing using Performance Based Financing (TUSY02)
• 24 facilities Rwanda (Bautista-Arredondo) • Randomly selected facilities received 1 dollar
for each HIV test done (goes to clinic) in intervention
• Control sites received the same amount of money unlinked to performance
• Quantity and quality both used to assess reimbursement
• Intervention led to increased testing in the community by 11%
www.ias2013.org Kuala Lumpur, Malaysia , 30 June - 3 July 2013
Delivery Strategies: Hybrid Models (TUAD01)
• TASO in Eastern Uganda• Community drug distribution points model• 1,302 (38%) were facility based and
2,155(64%) were community based • Loss to follow-up was four times higher in the
facility arm (17% vs. 4%, p< 0.0001).• Fewer deaths were reported in the CDDP arm
(4% vs. 6%, p=0.008)
www.ias2013.org Kuala Lumpur, Malaysia , 30 June - 3 July 2013
Quality of Care: More than the Cascade (WEPDD01)
Apr-Jun '11
Jul-Sep '11
Oct-Dec '11
Jan-Mar '12
Apr-Jun '12
Jul-Sep '12
0
10
20
30
40
50
60
70
80
25
4252 51
55
68
Aggregated TB treatment completion rates; 16 project-supported hospitals
% T
B p
atie
nts
com
plet
ing
treat
men
t
CQI training & team formation
Quarterly mentorship
& QI coaching
Orientation on indicator
definitions and reporting tools
Integrated clinical
mentoring and QI coaching
Using QI methodology to improve care in Uganda (Mutesasira)
www.ias2013.org Kuala Lumpur, Malaysia , 30 June - 3 July 2013
Track D: Summary• There is no single cascade: know your cascade, know your
implementation “gaps”– Understand common barriers across the cascade
• Circumcision and PMTCT –progress but barriers remain– Public health must meet patients half-way
• Innovative Delivery Strategies– Mobile testing, community drug distribution points, social
“capital,” mHealth • Quality
– Growth of quality improvement movement as well as performance based financing
www.ias2013.org Kuala Lumpur, Malaysia , 30 June - 3 July 2013
Implementation Science: the Way Forward
• Progress is being made, but gaps remain• Invest in implementation science to find generalizable strategies to close
these gap• Interdisciplinary teams
– Industrial engineering, marketing, sociology, economics, anthropology, etc. • Innovative research designs
– Hybrids design to understand effectiveness and implementation– Adaptive interventions, modular designs
• Build on existing knowledge about real world change– Behavioral economics, PRECEED, CFIR and others– Diffusion of innovations: Identify the core, understand adaptable periphery,
evaluate comparative effectiveness and scale up• Foster implementer – researcher partnerships: ensure “practice based
evidence” and pragmatic research