ICAP Track 1.0 Year 6:

Reaching Targets

Focus on Quality

Continued Innovations

David Hoos, MD, MPHDar es SalaamAugust 4, 2009

ICAP/Columbia University In Africa

Measurement: ICAP Program and Facility Characteristics Tracking System (PFaCTS)

A survey tool for site characteristics

to monitor and guide

implementation

ICAP Unified Reporting System (URS)

Reaching Targets

0

50

100

150

200

250

300

350

400

450

500

0

100,000

200,000

300,000

400,000

500,000

600,000

700,000

Mar-05 Mar-06 Mar-07 Mar-08 Mar-09

HIV Care ART Facilities Currently Reporting

EthiopiaLesotho, Rwanda,S. Africa, Tanzania

Mozambique

Nigeria,

Zambia

Cote

d’Ivoire

436 sites

613,005 in care

Cumulative enrollment in HIV care and treatment programs (436 sites)

I

298,668 on ART

Nu

mb

er o

f p

atie

nts

Nu

mb

er of facilities

Swaziland

0

50

100

150

200

250

300

350

400

450

500

0

10,000

20,000

30,000

40,000

50,000

60,000

70,000

Mar-05 Mar-06 Mar-07 Mar-08 Mar-09

HIV Care ART Facilities Currently Reporting

Cumulative pediatric enrollment in HIV care programs (436 sites)

436 sites

28,031 on ART

Nu

mb

er o

f p

atie

nts

Nu

mb

er of facilities

63,364 in careLesotho,

Rwanda,S. Africa, Tanzania

Mozambique

Nigeria,

Zambia

Cote

d’Ivoire

Ethiopia

Swaziland

Magnitude of new enrollment per half year continues to rise

Num

ber

of p

atie

nts

7,682

20,115

33,096

43,978

60,165

67,270

80,732

89,80693,913

1,2265,061

12,90217,061

25,00829,621

34,814

40,679 41,255

0

10,000

20,000

30,000

40,000

50,000

60,000

70,000

80,000

90,000

100,000

Oct '04 -Mar '05

Apr '05 -Sep '05

Oct '05 -Mar '06

Apr '06 -Sep '06

Oct '06 -Mar '07

Apr '07 -Sep '07

Oct '07 -Mar '08

Apr '08 -Sep '08

Oct '08 -Mar '09

New Care Enrollment New ART Enrollment

59%

69% 67% 66%62% 61% 61% 59% 59% 57% 55%

1%

10%4% 3%

7% 7% 11% 11% 9% 11% 11% 9%

99%

0%

50%

100%

Women 15+ Children <15

Children represent 10% and women 59% of those enrolled in care

(cumulative to March 2009)

% p

atie

nts

in H

IV c

are

n=36

,875

n= 4

2,09

7

n=61

3,00

5

n=2,

605

n=71

,370

n=41

,916

n=51

,169

n=79

,908

n=72

,050

n=10

,073

n=17

6,42

5

n=35

,517

58%

66% 64% 64% 64%61% 60% 58% 58% 56%

53%

1%

9%4% 4%

8% 6% 7%11% 10% 10% 9% 7%

98%

0%

50%

100%

Women 15+ Children <15

% p

atie

nts

on A

RT

Children represent 9% and women 58% of patients initiating ART

(cumulative to March 2009)

n=18

,096

n= 3

5,17

4

n=29

8,66

8

n=1,

585

n=20

,399

n=22

,989

n=32

,227

n=41

,022

n=42

,344

n=4,

098

n=22

,996

n=57

,338

Increasing numbers of pregnant women counseled, tested & receive ART for PMTCT

# o

f W

om

en 109,421

128,144

167,076

96%

96%

92%

91%

94%

93%

11% 87% 8%44% 84% 70%

0

20,000

40,000

60,000

80,000

100,000

120,000

140,000

160,000

180,000

Oct 2007 - Mar 2008 Apr - Sept 2008 Oct 2008 - Mar 2009

1st ANC Counseled Tested HIV Positive ART Prophylaxis

Increasing number of individuals counseled and tested over time

April-June 2008 July-Sep 2008 Oct-Dec 2008 Jan-March 20090

50,000

100,000

150,000

200,000

250,000

300,000

116,620

176,774

252,487239,592

# P

ers

on

s

Focus on Quality

Indicators of QualityI. Providing Comprehensive Services

92%85% 88%

83%74%

0%

50%

100%

VCT PMTCT Labor & Delivery

TB Treatment ART Pharmacy

Most ICAP-supported sites offer comprehensive HIV-related clinical services

% s

ites

with

ser

vice

s

Source: ICAP PFACTS, July 2008

Increasing proportion of ICAP-supported sites offering supportive services

23%

35%

49%

93%

16%

28%

41%

68%

96%

20%

30%

43%

70%

98%

39%

0%

50%

100%

Food support for adults

Food support for adults or

children

Outreach Adherence Support

Peer educators

Jan-07 Jul-07 Jul-08

% o

f si

tes

Source: ICAP PFACTS, July 2008

Diverse prevention services offered at most ICAP-supported sites

97% 96%

87%

68%63%

23%

0%

50%

100%

Counseling regarding disclosure

Education on behavior and

safe sex

Provision of condoms

Referral for on-site screening

for STIs

Education on high-risk

substance abuse

Screening for drug and

alcohol abuse

% s

ites

Source: ICAP PFACTS, July 2008

35%48% 45%

32%

4% 6%

60%47% 48%

58%

78%

32%

0%

50%

100%

CD4 count Blood Chemistry

LFT CD4 percent

Infant Diagnosis /

PCR

HIV-RNA

Available On-Site Available Off-Site

High proportion of ICAP-supported sites provide access to key laboratory assays

% s

ites

Indicators of QualityII. TB screening in newly enrolled patients

Evidence of TB/HIV Integration

53%

63% 64%69%

63%67%

64%

0

200

400

0%

50%

100%

Sep-07 Dec-07 Mar-08 Jun-08 Sep-08 Dec-08 Mar-09

% Screened # Sites Reporting

n=17,762 n=18,753New HIV patients

n=23,142 n=24,705 n=33,013 n=29,319 n=32,731

Increasing proportion of sites offer TB screening & substantial proportion of patients screened

% o

f p

atie

nts

Persistent focus on TB/HIV integration by ICAP clinical advisors ‘pays off’ over time

Mar-07 Jun-07 Sep-07 Dec-07 Mar-08 Jun-080%

50%

100%

44% 44%

55% 57%

63%

76%

Indicators of Quality

III. Uptake of combination regimens for PMTCT

37% 41%36% 36% 33%

29%22%

11%

48%47% 56% 51% 53% 60%

66%77%

15% 12% 8% 12% 13% 12% 12% 11%

0%

50%

100%

Jun-07 Sep-07 Dec-07 Mar-08 Jun-08 Sep-08 Dec-08 Mar-09

sd-NVP Multi-Drug Regimen initiated ART

n=2,247 n=2,536 n=2,931 n=3,966 n=3,587n=1,216 n=1,932 n=3,739

Successful shift to combination PMTCT regimens at ICAP-supported sites

% o

f W

om

en

Rapid shift in maternal regimens for pMTCT: ICAP - Ethiopia

0%

50%

100%

Jan-07 Apr-07 Jul-07 Oct-07 Jan-08 Apr-08

% o

f P

atie

nts

SDNVP only SDNVP+AZT HAART

New national ART prophylaxis

guidelines implemented

SD/NVP onlySD/NVP & AZT

HAART

Rapid shift in infant regimens for PMTCT: ICAP- Ethiopia

0%

50%

100%

Apr-07 Jul-07 Oct-07 Jan-08 Apr-08

% o

f P

ati

en

ts

SDNVP only SDNVP+AZT

New national ART prophylaxis

guidelines implemented

SD/NVP & AZTSD/NVP only

Indicators of Quality IV. Patient monitoring

146

198

165 161

137 136124

115106

280

313 314

284 288

264 263 256

227

318

353345 342 345

316

287 291279

0

50

100

150

200

250

300

350

400

Overall Rwanda Mozambique Nigeria Tanzania Lesotho Ethiopia South Africa Kenya

Baseline 6-Month 12-Month

Robust increases in median CD4+ cell counts noted among cohorts of patients initiating ART

CD

4 C

ell

Co

unt (

cells

/ul)

n=7,759 n=5,712 10,581n=22,936n=9,162

n=7,682n=7,153n=97,163

n=26,178

Indicators of qualityV. Retention in care

Continued ART*243,285

81%

Discontinued ART, 55,383 19%

Stopped ART 5%

Reported Dead 34%

Lost to Follow-up 62%

Of 299,000 patients initiated ART, 81% continued ART

*Includes patients who transferred out while on ART.

.59% per year on

ART

5.2% per year on

ART

9.5% per year on ART

Loss to follow-up more likely in first 6 months after ART initiation (ICAP-Kenya)

Time since ART initiation (Months)

# at risk % Died% Lost to follow-up

% Lost to program

3 7,635 1.8 7.9 9.6

6 6,690 2.4 9.8 12.0

12 5,127 3.1 12.7 15.4

18 3,862 3.8 14.1 17.4

24 2698 4.5 15.4 19.2

Indicators of qualityVI. ART adherence

ICAP supported TRAC PHE in RwandaICAP supported sites 40% of total sample

High 30-day self-reported adherence in Rwandan national ART program sample

77.6 76.7 76.2

11.3 11.7 12.7

18.1 18.6 21.2

0%

50%

100%

6 months 12 months 18 months

100% adherent 90% adherent ≤80% adherent

N=575 N=489 N=352

% o

f p

atie

nts

83.3 81.8 83.8

9.9 9.8 8.16.9 8.4 8.1

0%

50%

100%

6 months 12 months 18 months

Undetectable/< 40 cp/ML 40 - 500 cp/ML > 500 cp/ML

N=335 N=285 N=222

Large proportion of patient with suppressed HIV RNA in Rwanda national program sample

% o

f p

atie

nts

Self-reported adherence consistent with HIV RNA suppression

84 84 8577

6273

0%

50%

100%

6 months 12 months 18 months

% w

ith

un

det

ecta

ble

vir

al l

oad

100% adherent <100% adherent

N=335 N=285 N=222

P<0.05

Innovations Continue

Strengthening TB ScreeningSouth Africa

Offering HIV testing to Male Partners of Women in Labor & Delivery Wards–

ICAP-Ethiopia

Prevention for Most at Risk Populations – Injection drug users in Zanzibar

ICAP-Tanzania

Services for Special Populations – Prisoners

ICAP- Cote d’Ivoire

Non – Traditional ProvidersICAP-Nigeria

Mobile Counseling and Testing in Rural Areas ICAP-Ethiopia

Laboratory Systems – Motorcycle Transport

ICAP-Tanzania

Expansion of Health Workforce – NursingMulti-country

Patient Empowerment through Income Generating Activities

ICAP-Nigeria

Care for Healthcare Workers with HIV ICAP-Kenya

Summary• Sites continue to be supported to provide

comprehensive services & expanded enrollment• Focus on quality:

– Expanded menu of clinical and supportive services– Integration of services– Incorporation of new knowledge– Quality indicators

• Continued innovations

Acknowledgements

ICAP country directors and their teamsIda Viho - CD Cote d’IvoireZenebe Melaku – CD EthiopiaMark Hawken CD KenyaJosue Lima CD MozambiqueBola Oyeledun CD NigeriaRuben Sahabo CD RwandaTshi Neluheni CD South Africa

Amy Cunningham CD TanzaniaICAP-NY Ministries of Health, provincial, district authorities, facility leadership & staffPartner organizationsPLHIV organizationsCDC leadership and staff