ICAP-Columbia University Track 1.0 Program (MCAP) Track 1.0 Meeting - Maputo August 2010

1. ICAP-Columbia UniversityTrack 1.0 Program (MCAP)Track 1.0 Meeting - MaputoAugust 2010

2. Outline of Presentation • Key programmatic achievements • Need for continued scale-up and innovations to aim for universal access • Focus on quality in the context of transition • Loss to follow up and retention • Data quality assurance • Transition activities for Track 1.0 • Summary and conclusions

3. Key Programmatic Achievements

4. The spectrum of HIV related portfolio of activities for ICAP-CU Number of sites Note: Some sites offer more than one activity

5. Continued increase in number of ICAP-supported facilities and enrollment in HIV care and treatment 652 facilities Swaziland Cote d’Ivoire Zambia Nigeria, Kenya 861,280 ever enrolled in care Lesotho, Rwanda, S. Africa, Tanzania Number of facilities Number of patients Ethiopia Mozambique 430,876 ever initiated ART

6. Cumulative enrollment in HIV care and treatment at sites currently supported by MCAP (Track 1.0) 488 facilities Cote d’Ivoire Nigeria, Kenya 683,838 ever enrolled in care Number of facilities Rwanda S. Africa Tanzania Number of patients Ethiopia Mozambique 334,157 ever initiated ART

7. Continued increase in numbers of new enrollees in HIV care and treatment per quarter Number of new patients Note: *New enrollment includes transfers

8. In each country, new ART enrollment rates are stable (site number constant) Number of new ART patients

9. Increasing number of children enrolled in HIV care and treatment 652 facilities Swaziland Cote d’Ivoire Nigeria, Zambia Kenya 73,367 ever enrolled in care Lesotho Rwanda S. Africa Tanzania Number of facilities Number of patients Ethiopia Mozambique 36,700 ever initiated ART

10. Increasing proportion of new TB patients with unknown HIV status tested for HIV Percent of patients TB patients with unknown HIV status n=5,992 n=6,397 n=8,416 n=8,750 n=8,907 n=10,003 n=7,613

11. Increasing proportion of new patient enrolled in HIV care screened for TB Percent of patients New HIV patients n=38,025 n=37,234 n=28,630 n=22,037 n=38,379 n=44,612

12. HIV testing and counseling (January-March 2010) Number of clients Source: ICAP URS March 2010 Notes: Data is not available for all indicators in all points of service. Not all countries are able to report enrollment into care and treatment

13. Aiming for Universal Access will require continued scale-up and innovation

14. ART coverage of estimated PLHIV eligible for treatment-- Central Province, Kenya

15. Expansion of access to newly eligible patients as per new WHO guidelines ART eligibility after 12-months of follow-up at 27 ICAP-supported sites CURRENT NATIONAL GUIDELINES REVISED 2009 WHO GUIDELINES 11,209 (30%) of 37,178 patients started ART during follow-up

16. Continued need to reach more children n=28,597 n=87,191 n=39,385 n=28,387 n=24,016 n=71,608 n=50,911 n=334,157 n=4,062 Percent pediatric patients on ART

17. Decrease in use of SD-NVP at ICAP-supported PMTCT programs but need to expand ART use, 2007-2010 ART Multi-drug ARV prophylaxis Percent (%) of HIV+ Pregnant Women sdNVP

18. Pregnant women as a proportion of all women initiating ART Percent of women

19. HIV testing must be focused to reach undiagnosed individuals‘Hot spots’ exist within regions (overall HIV prevalence and clinic VCT HIV prevalence)

20. New initiatives need to be scaled-up • Prevention in positives • Male circumcision (neonatal and adult/adolescent) • Interventions for most at risk populations • Drug users • Men who have sex with men • Adolescents

21. Implementing Partners and Districts Need to Focus on Quality,Retention and Loss-to-follow-up

22. Retention rates on ART from two meta-analyses of data from sub Saharan Africa 2009: 70% at 24 months 2007: 60% at 24 months Fox and Rosen, Tropical Med Intl Health 2010

23. ICAP ART retention compared to findings from Rosen 2007 & Fox 2010 Meta-Analyses ICAP ART Pt-Level Data, 2007-2009, N = 91,612 patients Fox 2010

24. Focusing solely on ART patient is traditional approach to retention and follow up ART eligible Pre-ART Dx ART ART in-eligible Lost-to-follow-up: Death, Stopped care, Transfer, Unknown

25. ICAP Focus on Retention HIV Care and Treatment ART eligible ART Dx Pre-ART ART in-eligible CHRONIC CARE CHRONIC CARE

26. Retention across the continuum of HIV diagnosis, care and ART ART eligible Pre-ART Dx ART ART in-eligible Lost-to-follow-up: Death, Stopped care, Transfer, Unknown

27. Use of aggregate data to evaluate retention • Routinely collected in all country programs • Data quality limited by: • Dependent on ‘status’ designation • Limitations of data in registers • Currently only retention data is available for patients who initiated ART

28. Cumulative patients initiating ART and their current status (n= 430,876) Cumulative ever initiating ART Lost to follow up Reported dead Number of patients ART patients currently retained in HIV care*

29. Status of ART patients, as of March 31, 2010 (n= 430,876) Rates 9.1% per year on ART Lost to Follow-up 4.7% per year on ART Reported Dead Reported stopped ART 3% .44% per year on ART Notes: *Includes patients who transferred out while on ART.

30. Use of patient-level data to evaluate retention • Cohort data of pre-ART and ART patients • LTFU data based on clinic, pharmacy or lab visits • Five countries, ~235,000 patients, 100 sites • Disposition of patients still influenced by availability of active follow-up

31. ART Patients at ICAP-supported sites (Patient-level data) Two-year cumulative risk of death, loss to follow-up9, and loss to program8among ART patients since ART initiation (Total 113,000 patients); through March 2010 77% Retained at 2 years

32. High retention of pediatric ART patients Rwanda through March 2010 (n= 30 sites) 90% Retained at 2 years

33. Pre-ART Patients All Patients(Adult and Pediatric) through March 2010 (n= 185,898) 66% retained at 6 mo 52% Retained at 2 years

34. Better retention at rural versus urban sites

35. Better retention since ART initiation at primary health facilities • versus secondary or tertiary facilities

36. Sites offering on-site patient support services that could influence retention (n=323) % sites with service

38. ICAP Data Quality Assurance (DQA) Indicators • Standardized DQA will assess the completeness and accuracy of key routinely reported indicators • Programs will modify/incorporate standardized approach into routine DQA exercises • ICAP-wide DQA indicators will be reported every other quarter for a specified past quarter of interest • Findings will inform transition of collection of high quality data at Districts

39. DQA Indicators * Quality Indicator

40. Track 1.0 transition efforts

41. Examples of transition activities • The size and scope of subcontracts with local government are increasing • Institutional capacity building of local government is a particular focus – success here will be the eventual test of transition • Intermediate stage of transition to local NGO

42. Summary • Continued expansion of enrollment and programmatic diversity • Urgent continuing need to expand coverage and reach new populations • Expansive vision of retention in program • Data quality is a priority to inform programs • Country specific approaches to transitioning to local partners

43. The Emergency is not over! Work must continue to reach universal access to high quality prevention and care