Phyllis Kanki Harvard School of Public Health VIIIth Annual Track 1.0 ART Meeting August 2010.

Phyllis KankiHarvard School of Public Health

VIIIth Annual Track 1.0 ART Meeting August 2010

100,000

420,000

750,000

0.0 0.5 1.0 1.5 2.0

Botswana

Tanzania

Nigeria

HIV Infection

AIDS Cases

140 Million

36 Million

2 Million

Million

2.5 3.0

Harvard PEPFAR program

Initiated on ART

HIV Care and Treatment

Botswana Nigeria Tanzania Total

Persons ever enrolled in HIV Care 18,975* 118,688 95,389 233,052

Persons ever initiated on ART 13,578* 76,166 61,433 151,177

Number of ART Facilities154 26 50 230

Number of PMTCT Facilities --- 61 133 194

•Clinical master trainers – adult patients only

MDH supported sites in Dar es Salaam (n=50)

PUBLIC PRIVATE

Total ever enrolled95,389

(7.6 % children)

Active on ARVs 45,699( 7.6 % children)

Ever initiated ARVs61,433

(8% children)

Collaborating institutions (MDH):

Muhimbili University of Health & Allied Sciences (MUHAS)Dar es Salaam City CouncilHarvard School of Public Health

June 2010

Patient retention

25.6% of patients ever initiated ARVs are not active

Timely tracking of patients who missed their appointment dates at the clinic by phone calls or physical visits.

Major reasons: Deaths Transfers Refusal to continue Unknowns

6035 (95.8%) of missing patients were tracked for the last quarter

73.4% of those tracked had their vital status ascertained

Patients retention Future Plans to improve

tracking Pairing of counselors/clinicians with a number of patients

Improve understanding, communication and interaction with patients

Create bond between patients and their counsellor/clinicians

Counsellors/clinicians will be able to follow up patients development

Make use of existing NGOs (Pathfinder) who work at community level

Introduce electronic model of tracking, recording and reporting

PMTCT Achievements (133 sites)Oct-Dec 08

Jan-Mar 09

Apr-Jun 09

July-Sept 09

Oct-Dec 09

Jan-Mar 10

Apr-Jun10

Total tested 19,335

21,116 20,741

21,808

25,937

28,166 24,298

Overall prophylaxis

26.7% 33.7% 51.5% 69.6% 56.6% 61.2% 80.5%

HIV exposed infants registered

- 518 549 356 310 1357 1389

Confirmed +ve - 7 2 1 1 94 98

Cotrimoxazole Prophylaxis

- 371 13 184 205 179 229

EID Sites - 13 13 14 42 58 65

7% infection

Public – Private Partnership (PPP)

There is significant contribution from private hospitals

• 6.5% of patients from MDH supported sites are treated at private hospitals

• Contribute in offloading patients from already overwhelmed public sites

• Provide more options for the patients

• Contribute towards “access to all strategy”

Botswana’s Masa ART Program

121,644 patients on ART in the public sector at present (May 2010)

61.4% female; 6.3% children

14,995 patients out-sourced from the public to the private sector –(Public-Private-Partnership [PPP])

13,394 patients in the private sector (Medical Aid Schemes and the Work-place Programs)

TOTAL: 150,033

(92.8% of need for adults and children)

Master Trainer/ARV Site Support Program

Clinical Laboratory

Monitoring & Evaluation Unit Linked to:

• All ARV sites• Other MOH programs

Masa

BHP-PEPFAR ARV Site Support Program

Clinical Master Trainer Program : ARV Sites Assessed and

Supported

Mother Sites

MiddlepitBokspit

Goodhope

Palapye

Masunga

Werda

KalkfonteinNewxade

Each Mother Site has 3-4 Clinics

Task Sharing

Nurse Prescriber & Dispenser Training to Date

- 246 nurses trained in prescribing and dispensing ARVs

- 680 nurses trained in ARV dispensing only

Nurse training for Rapid HIV testing and Dried Blood Spot collection in collaboration with PMTCT (38 trained in 4 trainings this quarter)

Laboratory Capacity Building

At start of PEPFAR – 2004:2 HIV reference labs performed all CD4 and Viral

Load testing for the country

In 2010: Botswana Lab Master Trainers have trained and

supported ALL decentralized labs and private sector labs which run PPP specimens

CD4s - 24 decentralized labs performing 62% VL – 10 decentralized labs performing 33%

Reasons for Site Support Calls

Analysis of 100 calls from BHP Master Trainers Telephone Site Support

New InitiativesPatient Information Management System –currently

developing integrated PIMS II system for PMTCT, HCT, ARV and planning roll-out

Pharmacovigilance

Failure Management Registries

Adolescent –focused programs and training

First data collection for Quality Improvement

Updated analysis of integrated MASA dataset that now has records for over 110,000 patients

Harvard PEPFAR Nigeria•Through Bill & Melinda Gates funding, Harvard has

been working with multiple hospitals and prevention programs in Nigeria since 2000

•Started PEPFAR ART activities at 6 tertiary hospitals in 2004 and expanded to a total of 26 sites.

•Transitioned 14,100 ART current patients to APIN Ltd

Year 1 Year 2 Year 3 Year 4 Year 5 Year 6

Cumulative in Palliative Care

Adults 6,151 18,518 36,504 59,051 75,512 113,567

Pediatrics 449 1,132 2,167 3,060 5121

Cumulative on ART

Adults 2,760 12,165 23,108 38,050 55,793 72,906

Pediatrics 97 485 1,284 1,951 3,260

Time-to-failure:Patients identified by both criteria

Median time to virologic failure11.1 months

Median time to CD4 failure15.3 months

Viral load monitoring identified failure significantly earlier than CD4 criteria (p<0.0001)

Patients maintained on virologically non-suppressive ART over a median of 6 months developed an average of 1.96 IAS-mutations with a loss of 1.25 active drugs (Cozzi-Lepri et al. AIDS 2007; 21:721.)

Virologic Failure

Immunologic Failure

% T

reat

men

t S

ucce

ss

11.1 mo.

15.3 mo.

TDF-3TC-NVP (n=813) is Inferior to AZT-3TC-NVP multivariate analysis on virologic failure

Failure at 12 months was 16.1% for TDF-3TC-NVP versus 9.5% AZT-3TC-NVP K.Scarsi et al. Vienna, 2010

PMTCT Transmission Rates (n=5320)

Meloni et al, 2010

No statistically significant difference between ART and mono or bi-ART prophylaxis

Patient Monitoring: Pharmacy Database Adherence Utility

-------------------------------------BLANKED OUT-----------------------------

•Assess adherence to treatment based on timeliness of drug pick-ups

•Use calculation of average percent adherence

•Setting up networks so that pharmacists can cross-check prescriptions

Ahmadu Bello University Teaching Hospital Loss to Follow up Rate

Lower in ARV Experienced vs. Naïve Patients n= 3001

Comparison of LTFU among Large Treatment Programs in Africa

Assessment of causes of early & late LTFU may elucidate potential interventions

Country # Patients

Analyzed

Duration of Follow-up

LTFU rate Comments: LTFU definition

South Africa

CID 2006; 43:770.

1235 pts

(Sep 02 -Aug 05)

35 months 33.3% early mortality

(2.3% LTFU)

LTFU: >4 weeks late for scheduled visits and were not deaths or transfers

South Africa

JAIDS 2008; 47(1):101.

1631 pts

(Apr 04 - Jun 05)

15 months 16.4% LTFU during 15 mo F/u

LTFU: >6 weeks with no visit or pharmacy pick-up

Nigeria

PLoS 2010; 5(5):e10584.

5760 pts

(Mar 05 - Jul 06)

16 months 26% lost at any time during 16 month follow-up

LTFU: Did not return >60 days from expected visit

Risk factors: CD4>350 or <100, etc.

Nigeria

ABUTH LTFU Data

3001 pts

(Jun 06 - May 09)

35 months 22.6% LTFU at 12 months of follow-up

LTFU: >2 months since missed visit or pick-up

APIN/PEPFAR Sites: 2010

Federal Medical Centre Makurdi

Federal Medical Centre Makurdi

Jos University Teaching Hospital

Our Lady of Apostles Hospital Jos

8 Satellite Hospitals, 44 PHCs

Jos University Teaching Hospital

Our Lady of Apostles Hospital Jos

8 Satellite Hospitals, 44 PHCs

University of Maiduguri Teaching Hospital

State Specialist Hospital MaiduguriNursing Home Maiduguri

University of Maiduguri Teaching Hospital

State Specialist Hospital MaiduguriNursing Home Maiduguri

University of Nigeria Teaching Hospital

University of Nigeria Teaching Hospital

Ahmadu Bello University Teaching Hospital

Ahmadu Bello University Teaching Hospital

Nigerian Institute for Medical Research Lagos University Teaching Hospital

University of Lagos, College of Medicine Mushin General Hospital

PHC-Iru Victoria Island Onikan Women’s Hospital

Nigerian Institute for Medical Research Lagos University Teaching Hospital

University of Lagos, College of Medicine Mushin General Hospital

PHC-Iru Victoria Island Onikan Women’s Hospital

Sacred Heart Catholic Hospital Lantoro

Sacred Heart Catholic Hospital Lantoro

University of Ibadan College of Medicine

3 Satellites under UCHAdeoyo Maternity Hospital

43 Oyo DOTS Centres

University of Ibadan College of Medicine

3 Satellites under UCHAdeoyo Maternity Hospital

43 Oyo DOTS Centres

Widowcare Abakiliki Ebonyi

Widowcare Abakiliki Ebonyi

APIN Program Office

Sites Under Harvard PEPFARSites Under APIN Ltd

Sites Under APIN Ltd

Federal Medical Centre Nguru

Federal Medical Centre Nguru

68 Nigerian Military Hospital Creek Hospital

• Continual training is a critical foundation for optimal prevention, treatment and care programs and sustainability

• Rigorous program evaluation is critical to inform national guidelines and insure optimal care.

• Developing systems for program outcome and impact will facilitate country ownership and sustainability

Botswana

R. Marlink

P. Burns

T. Gaoloathe

J. Mukhema

N. Ndwapi

I. Thior

M. Mine

C. Bussmann

Tanzania

W. Fawzie

G. Msamanga

D. Mtasiwa

G. Chalimilla

S. Kaaya

C. Hawkins

S. Ismail

M. Mwanyika-Sando

Nigeria

P. KankiS.Meloni

R. Murphy S. HosseiniJ-L Sankalé H.RawizzaB. Chaplin A. OjesinaK. Scarsi K.

HurtB. Taiwo

A.Dieng SarrP. Okonkwo J. SamuelsE. Ekong P.

AkandeT. Jolayemi B. AlukoR. Olaitan S. SagayS. Ochigbo O. AgbajiO. Idigbe S.

AkanmuS. Ogunsola W. GashauM. Garbati C. OkanyI. Adewole R. NkadoD. Olaleye H. MuktarD. Owujekwe J. AbahO. Eberndu N. Nulenga