Presentation: Results of National Adherence PHE

National HIV Prevention , Care and National HIV Prevention , Care and Treatment Program Treatment Program

TRAC Plus

Center for Treatment and Research on AIDS, Malaria, Tuberculosis and Other Epidemics

Adherence Technical Meeting October 19th - 22nd, 2009

Jules Mugabo M.D

HIV, AIDS and STI Unit

TRAC Plus/ Rwanda MOH

HIV Prevention Program

HIV testing (VCT, PMTCT and PIT): Pregnant women and their partners under PMTCT Exposed children Couples and children in VCT Youth (youth at street) Sex workers and theirs clients Truck drivers Soldiers

IEC/BCC Condom Family Planning

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VCT National program 2004-2008

2004 2005 2006 2007 2008

Estimation of general population (census 2002) 8,577,753 8,814,253 9,058,392 9,309,619 9,567,190

Targeted population for VCT (50% of the general population) 4,288,877 4,407,127 4,529,196 4,654,810 4,783,595% Of clients tested (denominator: Targeted population for VCT)

4.1% 10.2% 10.4% 16.1% 20.2%

HIV seroprevalence in VCT

11.4% 9.4% 7.3% 4.8% 3.4%

% of Health facilities offering VCT 26.5% 46.2% 51.8% 63.1% 75.4%

2004 2005 2006 2007 2008

Rwanda population (census 2002) 8,577,753 8,814,253 9,058,392 9,309,619 9,567,190Expected pregnant women

351,688 361,384 371,394 381,694 392,255

% of pregnant women tested for HIV

27% 49% 59% 56% 75%

% of HIV + women receiving ART prophylaxis

35% 51% 60% 55% 67%

% of exposed children receiving ART prophylaxis

26% 33% 46% 65% 63%

% of partners tested for HIV in PMTCT

ND 32,6% 52,4% 65% 78%

% of discordant couples in PMTCT

ND 4,5% 3,7% 3,1% 2,7%

% of Health facilities providing PMTCT

26.5% 46.2% 51.8% 63.1% 75.4%

PMTCT Program 2004-2008

Level of participation in PMTCT program

Rate of MTCT of HIV

Barriers to PMTCT use

The most mentioned barriers are: Ignorance : some healthy women do not

understand the benefits of ANC Fear for HIV test and discrimination towards

PLWHA: they cannot bear HIV+ status and discrimination that follows

Extra marital pregnancies: unmarried girls, widows and single mothers do not attend ANC and PMTCT because they tend to hide their pregnancies

Barriers to PMTCT use

Partner: some HIV+ women' partners who do not disclose, unwanted pregnancy do not utilize ANC or PMTCT

Health facility: too long waiting time, lack of confidence in performing reliable lab tests, out of stock of ART, Painful physical exams, requirement of partner attendance,…

Overwhelmed: women with many children fail to use ANC services because they are overwhelmed by housework

Geographic accessibility: long distance can prevent pregnant women to attend required ♯ of ANC

Reasons for less adherence of pregnant women to PMTCT services

1 Out of health facility delivery: The main cause of delivering at home or in the street was that some women get surprised by the labor and deliver at home or before they reach the health facility.

2 Poverty: lack of money for transportation or for medical care, long distances, and lack of relatives to go with at health facility are reasons why they do not give birth in health facilities.

Others: unwanted pregnancies,…

PMTCT clients challenges and program PMTCT clients challenges and program weaknessweakness

• Breastfeeding: the mix of breastfeeding and complementary diet after six month because they can’t afford breastfeeding replacement: “…we are obliged to continue to breast feed our baby after though we know we are infected because we can’t let the baby starve”

• Required ♯(CPN) ANC: Misunderstanding of the importance of ANC, lack of support from husbands and relatives .

• Incomplete package of PMTCT services at some Health centers

HIV Care and Treatment

OI prophylaxis (CTX, Dapsone, fluconazole…)

Screening, diagnosis and management of: STI OI (TB, Cryptococcal

meningitis Side effects

Provision of ART Patients monitoring and

follow up

Psychosocial and adherence support

Nutrition program Family Planning Prevention with positive PBF Community based

intervention (HBM, IGA, OVC, Mutuelles,…)

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2004 2005 2006 2007 2008

Estimation of general population (census 2002) 8,577,753 8,814,253 9,058,392 9,309,619 9,567,190

Adults

HIV+ adult (15+) 158,275 157,157 162,837 170,639 177,258Adults in need of ARVs 50,106 48,733 49,316 52,949 92,421Proportion of eligible adults receiving ART

18% 36% 64% 80% 62%

Children

HIV+ children (0-14) 29,373 29,621 29,878 30,275 31,299Infants in need of ARVs 7,625 7,395 7,517 7,912 8,544Proportion of eligible children receiving ART

7% 20% 37% 55% 66%

Services coverage

% of Health facilities offering

7% 18% 29% 36% 43%

ART Program 2004-2008

Patients on ART end June 2009 =70,234 patients)

ARV regimen % patients

96.58 % of adults

patients

D4T+3TC+NVP 48.07AZT+3TC+NVP 34.82D4T+3TC+EFV 5.40

AZT+3TC+EFV 8.29

Type of health facility Children Adults

Hospital 37.3% 36.5%Health center 62.7% 63.5%Total 100% 100%

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TB Screening in Patients Newly Enrolled at 123/194 (63%) HIV Care and Treatment Clinics in Rwanda, S2 2008, n=10668

The prevalence of TB in newly enrolled patients was 226/9451 (2.39%)

0

2000

4000

6000

8000

10000

12000

newly enrolled screened scr + TB

89%

13%18%

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TB Screening at Follow Up Visits for Patients Enrolled > 6 Months at 104/194 (54%) HIV Care and Treatment Clinics in Rwanda, S2 2008, n= 48908

The incidence of TB among pts enrolled into care for > 6 months was 254/31571 (0.44%)

0

5000

10000

15000

20000

25000

30000

35000

40000

45000

50000

enrolled >6m screened scr+ TB

65%

7%11%

Evaluation of Clinical and Immunologic Outcomes from the National ART Program

RetentionFor this evaluation, patients who were dead, lost to follow-up, stopped treatment, or transferred were not considered to be retained

92% of adults and 93% of children remained on ART at their original site at 6 months of therapy

86% of adults and 89% of children remained on ART at their original site at 12 months of therapy

Evaluation of Clinical and Immunologic Outcomes from the National ART Program

Mortality Of adults who initiated ART: by 12 months, 4.6% were

dead, 5% were lost-to-follow-up, 0.3% had stopped treatment, and 4% had transferred out

Of children who initiated ART: by 12 months, 2.6% were dead, 4% were lost-to-follow-up, 4% had transferred out, and none had stopped treatment

Evaluation of Clinical and Immunologic Outcomes from the National ART Program

CD4+ Cell Count Change At ART initiation, the median adult CD4+ cell count

was 141cells/µL

For adult patients with follow-up data, median CD4+ cell counts increased by 98 cells/µL at 6 months and 119 cells/µL at 12 months, suggesting that, on average, adult patients had CD4+ counts of more than 250 cells/µL at 1 year after initiating ART

Evaluation of Clinical and Immunologic Outcomes from the National ART Program

CD4+ Cell Count Change For children with follow-up data, median CD4+ cell

count changes at 12 months were increases from baseline of:

399 cells/µL for children <24 months old 223 cells/µL for children 2–5 years of age 236 cells/µL for children 6-14 years of age

100% self-reported adherence during3 and 30 days

93.4 92.7 93.2 93.177.6 76.7 76.2 76.9

0%

20%

40%

60%

80%

100%

6 months N=576 N=575

12 months N=494 N=490

18 months N=355 N=352

Total N=1425 N=1417

% o

f re

sp

on

de

nts

3-day recall

30-day recall

Outcome: Self-reported adherence: 30-day recall

0%

20%

40%

60%

80%

100%

6 months 12 months 18 months

≤80% adherent

90% adherent

100% adherent

N=575 N=490 N=352

Current viral load

83.3 81.8 83.8 82.9

10.4 9.8 8.1 9.66.3 8.4 8.1 7.5

0%

20%

40%

60%

80%

100%

6 months N=335

12 months N=286

18 months N=221

Total N=842

% o

f res

po

nd

ents

wit

h v

iral

load

> 500

40 - 500

Undetectable/ < 40

Timing of missed pills among patients reporting ≤100% adherence in 3 days

preceding interview

0%

20%

40%

60%

80%

6 months N=47

12 months N=42

18 months N=26

Total N=115

% o

f res

pond

ents

repo

rtin

g <1

00%

adh

eren

ceMorningAfternoonEvening Night

Most common reasons for ever missing ART

Patient’s level factors predicting self-reported 30-day non-adherence …

OR 95% CI pvalue OR 95% CI pvalue

Sex (ref=female) Male

Age (ref=18-30 yrs) 31-36 yrs 0.658 (0.450 - 0.963) 0.0310 37-43 yrs >= 44 yrs 0.365 (0.233 - 0.571) <0.001 0.513 (0.268 - 0.980) 0.0432

Education (ref= No education) Primary Secondary/tertiary

Number of household members (ref= ≤4)

5-6 ≥7 1.585 (1.102 - 2.278) 0.0130Number of sitesSample size

6 monthsTotal

2020387999

Patient’s level factors predicting self-reported 30-day non-adherence …

OR 95% CI pvalue OR 95% CI pvalue OR 95% CI pvalue OR 95% CI pvalue

Percent of household members with HIV (ref=≤25%)

26-40% 0.516 (0.273 - 0.973) 0.0408

41-100%

Percent of household members on ART (ref= < 25%)

26-40% 0.309 (0.124 - 0.766) 0.0113

41-100% 0.311 (0.145 - 0.669) 0.00279Time to reach clinic, minutes (ref= ≤30 min )

31-90 min 0.647 (0.442 - 0.946) 0.0245 0.371 (0.198 - 0.698) 0.00210

>90 min 0.538 (0.346 - 0.835) 0.00567 0.386 (0.199 - 0.748) 0.00483

Number of sitesSample size

20 2020387 360 252999

6 months 12 months 18 monthsTotal

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Patient’s level factors predicting self-reported 30-day non-adherence …

OR 95% CI pvalue OR 95% CI pvalue OR 95% CI pvalue OR 95% CI pvalue

ART pickup visits per person year (ref < 12)

13-18 ≥19 3.536 (1.941 - 6.443) <0.001

CD4 count at initiation, cells µl (ref=CD4 100-199)

<100 0.59 (0.354 - 0.983) 0.0430

> =200How effective has ART been (ref=very effective)

Somewhat/not effecrive 2.557 (1.412 - 4.631) 0.00195 3.202 (1.281 - 8.004) 0.0128 5.277 (1.757 - 15.856) 0.00304Side effects in past 30 days (ref=none/few)

Moderate 1.61 (1.079 - 2.404) 0.0198

Severe 1.872 (1.190 - 2.946) 0.00666

Participate regularly in PLWHA meeting (ref = yes)

No 0.452 (0.232 - 0.883)0.0201

6 months 12 months 18 monthsTotal

Facility level factors predicting self-reported 30-day non-adherence …

OR 95% CI pvalue OR 95% CI pvalue OR 95% CI pvalue OR 95% CI pvalue

Cumulative site ART enrollment (ref=≥600)

≤199 200-599 0.332 (0.173 - 0.638) <0.001

PBF initiation (ref=≥2007)2004-2005 0.243 (0.0685 - 0.8623) 0.0286

2006 0.58 (0.381 - 0.884) 0.0112Year ART services initiated (ref=2003-2004)

2005 0.555 (0.352 - 0.876) 0.0114

2006-20007 0.428 (0.235 - 0.781) <0.001Adherence support available at site (ref=no)

Peer educators program 2.39 (1.492 - 3.828) <0.001

Support visits PLWHIV at home 0.436 (0.299 - 0.638) <0.001 0.493 (0.257 - 0.947) 0.0336

6 months 12 months 18 monthsTotal

Perspectives

Decentralisation and integration of HIV services (full coverage)

Task shifting: Physician to nurses Nurses to community health workers

Reinforce HIV Prevention strategy

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Murakoze

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