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Monitoring Systems for Antiretroviral Treatment Programs

Monitoring Systems for Antiretroviral Treatment Programs. Hitesh Hurkchand. Today’s presentation. Review the Epidemiology of HIV Global ART Statistics Global response to ART Monitoring Case study – South Africa. Current trends in HIV. Global epidemiology Regional trends.

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Monitoring Systems for Antiretroviral Treatment Programs

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  1. Monitoring Systems for Antiretroviral Treatment Programs Hitesh Hurkchand

  2. Today’s presentation • Review the Epidemiology of HIV • Global ART Statistics • Global response to ART Monitoring • Case study – South Africa

  3. Current trends in HIV • Global epidemiology • Regional trends

  4. Global Epidemiology THE OVERALL GROWTH OF THE GLOBAL AIDS EPIDEMIC APPEARS TO HAVE STABILIZED. THE ANNUAL NUMBER OF NEW HIV INFECTIONS HAS BEEN STEADILY DECLINING SINCE THE LATE 1990S AND THERE ARE FEWER AIDS-RELATED DEATHS DUE TO THE SIGNIFICANT SCALE UP OF ANTIRETROVIRAL THERAPY OVER THE PAST FEW YEARS. ALTHOUGH THE NUMBER OF NEW INFECTIONS HAS BEEN FALLING, LEVELS OF NEW INFECTIONS OVERALL ARE STILL HIGH, AND WITH SIGNIFICANT REDUCTIONS IN MORTALITY THE NUMBER OF PEOPLE LIVING WITH HIV WORLDWIDE HAS INCREASED.

  5. Global Epidemiology • 2.6 million new infections in 2009 • Incidence has fallen by more than 25% in 33 countries (2001 – 2009); 22 in SSA • 1.8 million new infections in SSA, in 2009 • Reduction attributed to prevention efforts and the natural course of the epidemic

  6. Current trends in HIV

  7. Regional Trends

  8. Global ART Statistics • An additional 1.2 million people received antiretroviral therapy in 2009, bringing the total number of people receiving treatment in low- and middle income countries to 5.2 million, a 30% increase over 2008. • At the end of 2009, 36% (about 5.2 million) of the 15 million people in need in low- and middle-income countries were receiving antiretroviral therapy. • Fewer people are dying from AIDS-related causes. About 14.4 million life-years have been gained by providing antiretroviral therapy since 1996. • About 50% of pregnant women testing HIV positive were assessed for their eligibility to receive antiretroviral therapy for their own health.

  9. Global ART Statistics • Children and marginalized populations (such as people who inject drugs) are less likely to receive antiretroviral therapy than the population at large. • While steady progress is being made in scaling up access to HIV services for people with tuberculosis (TB), the percentage of people with TB who received an HIV test in 2009 remained low, at 26%. Progress in scaling up TB services for people living with HIV is also very slow.

  10. As of Dec 2009, • In Sub Saharan Africa, 37% of people eligible for treatment were able to gain access • ART coverage for pediatrics were low • Number of facilities delivering treatment increased by 36% • Number of people receiving ART per health facility increased from 260 to 275 in 2009 • In 2010, WHO issued revised guidelines recommending early initiation of ART (CD4 <350) and increased the numbers eligible from 10 to 15 million!

  11. As of December 2009, • Achieving coverage of 80% or more (low to middle income countries) • Botswana, Cambodia, Croatia, Cuba, Guyana, Namibia, Romania and Rwanda • Achieving coverage of < 40% (low to middle income countries) • Cameroon, Ivory Coast, Ghana, India, Indonesia, Mozambique, South Africa, Ukraine, Tanzania, Vietnam and Zimbabwe

  12. Treatment 2.0 • Current approaches to treatment have not been optimal for the 15 million people in need. Treatment 2.0—a radically simplified treatment platform—holds promise to simplify treatment and provide all people needing it with a better pill less likely to lead to resistance, simpler diagnostics and monitoring, easier HIV testing, and more community empowerment. All stakeholders should unite to make this a reality.

  13. Global Response to ART Monitoring

  14. Key Components to ART Monitoring Basic data management

  15. Filing can feel like this…

  16. But we can make it easier!

  17. New Patient NURSE PATIENT EDU0812 CLERK DIARY FILING CABINET

  18. Returning Patient / Batching system PATIENT MISSED VISIT TO BE FOLLOWED UP CLERK DIARY FILING CABINET

  19. Missed Visit Files PATIENT MISSED VISIT TO BE FOLLOWED UP • DEATH • TRANSFER • LOST TO FOLLOWUP • UNKNOWN PATIENT EXIT CABINET FILING CABINET

  20. Summary • All patient files should be assigned a number • Patient files filed by number • Files should be batched based on return date in diary • Files from missed visits should be followed up systematically

  21. What did we do?

  22. Case Study – South Africa

  23. Total expenditure on the Comprehensive HIV/Aids conditional grant will amount to R26.9 billion over the mid term expenditure framework period, based on an increase in the number of people on treatment from 1.2 million this year to 2.6 million by 2013/14.

  24. Introduction • Primary Health Care facilities in South Africa currently do not have am standardized methodology for the capturing and processing of patient information on the ART programme. • This causes confusion and problems when reporting is required at facility, district, provincial and national levels.

  25. Introduction • A standardized register, clinical stationery and electronic media needs to be adopted for the capturing and tracking of patient information at health facilities. • This approach supports information integration at national levels for effective reporting.

  26. Background National Health Council approval a three-tiered strategy proposed by the National Department of Health to strengthen the routine monitoring of data used for ART patient management.

  27. Strategy The 3 phased intervention strategy consists of: • a standardized paper based system as a first phase (Tier 1) at health care facilities • an electronic stand-alone system as a second phase (Tier 2) for health care facilities • a fully networked patient management system in place as a third phase (Tier 3) for health care facilities

  28. Strategic Approach • Tier 1 – development of a paper based training solution for Provincial implementation • Tier 2 – evaluation of e-registers • Tier 3 – evaluation

  29. Tier 1 • Development of training curricula and standard operating procedures to support data management for ART. • Adoption of the WHO Patient Clinical Record Forms as a National standard. Revisions in 2010

  30. Tier 1 • Capacity development on usage of the patient cohort register through a series of workshops supported through National Department of Health and development partners • DHIS as a mechanism for collection of routine ART data

  31. But wait… • Data flow for routine information • Provincial structures • Monitoring at 2 levels • Point of care • Aggregated results at the district level

  32. Tier 2 • Evaluation conducted in October 2011 • The Western Cape HIV e-register was considered by the panel to be the most appropriate for use given that it has been working at scale, fits the panel’s definition of an electronic HIV register, performed well on all sections of the criteria

  33. Tier 2 • Infrastructure (stand alone desktop) • Standardized training curricula and standard operating procedures for Tier 1 and 2

  34. Tier 3 Evaluation complete • 40 systems were short-listed against set of defined standards • Evaluation of 9 systems

  35. Tier 3 Recommendations will support one system per province in addition to advising on Provinces ability (IT and other) to support the roll out of a patient electronic medical record system

  36. 3 Tier Approach • Standard operating procedures will provide guidance on absolute minimum criteria to be met in order to phase Tier 1 to 2 to 3 • Criteria to include programmatic benchmarks (#’s on treatment), availability of human resources, hardware and infrastructure requirements, etc.

  37. Dissemination • Dissemination of National Strategy • Communication to Provincial HAST and Information Managers • Communication to Development Partners and Department of Health – 31st March 2011

  38. Implementation Strategy Series of train the trainer workshops to be scheduled in support of the Tier 1 and 2 strategy Global Fund and National Department of Health resources to support printing of patient clinical forms and cohort registers. To be managed centrally

  39. Implementation Strategy Global Fund resources, National and Provincial Departments of Health and development partners to support procurement of hardware and human resources for Tiers 1 and 2

  40. Stakeholder engagement

  41. Case Study – South Africa • Implementation strategy • Development partners to support the implementation of Tiers 1 and 2 • Standards committee to approve changes in clinical stationery and future developments on Tiers 1, 2 and 3

  42. Rounding Up

  43. Thank you • Acknowledgements • MEASURE Evaluation • National Department of Health, South Africa • The Global Fund • UNAIDS • University of Pretoria • USAID and PEPFAR • WHO

  44. Questions

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