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

100, , , Botswana Tanzania Nigeria HIV Infection AIDS Cases 140 Million 36 Million 2 Million Million Harvard PEPFAR program Initiated on ART

HIV Care and Treatment BotswanaNigeriaTanzaniaTotal Persons ever enrolled in HIV Care 18,975*118,68895, ,052 Persons ever initiated on ART 13,578* 76,16661, ,177 Number of ART Facilities Number of PMTCT Facilities Clinical master trainers – adult patients only

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

Total ever enrolled 95,389 (7.6 % children) Active on ARVs 45,699 ( 7.6 % children) Ever initiated ARVs 61,433 (8% children) Collaborating institutions (MDH): Muhimbili University of Health & Allied Sciences (MUHAS) Dar es Salaam City Council Harvard 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 21,11620,741 21,808 25,937 28,16624,298 Overall prophylaxis 26.7%33.7%51.5%69.6%56.6%61.2%80.5% HIV exposed infants registered Confirmed +ve Cotrimoxazole Prophylaxis EID Sites % 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 ClinicalLaboratory 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 Middlepit Bokspit Goodhope Palapye Masunga Werda Kalkfontein Newxade Each Mother Site has 3-4 Clinics

Task Sharing Nurse Prescriber & Dispenser Training to Date nurses trained in prescribing and dispensing ARVs 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 Initiatives Patient 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 1Year 2Year 3Year 4Year 5Year 6 Cumulative in Palliative Care Adults6,15118,51836,50459,05175,512113,567 Pediatrics4491,1322,1673, Cumulative on ART Adults2,76012,16523,10838,05055,79372,906 Pediatrics974851,2841,9513,260

Time-to-failure: Patients identified by both criteria Median time to virologic failure 11.1 months Median time to CD4 failure 15.3 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 % Treatment Success 11.1 mo 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 rateComments: LTFU definition South Africa CID 2006; 43: pts (Sep 02 -Aug 05) 35 months33.3% early mortality (2.3% LTFU) LTFU: >4 weeks late for scheduled visits and were not deaths or transfers South Africa JAIDS 2008; 47(1): pts (Apr 04 - Jun 05) 15 months16.4% LTFU during 15 mo F/u LTFU: >6 weeks with no visit or pharmacy pick-up Nigeria PLoS 2010; 5(5):e pts (Mar 05 - Jul 06) 16 months26% 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 months22.6% LTFU at 12 months of follow-up LTFU: >2 months since missed visit or pick-up

APIN/PEPFAR Sites: 2010 Federal Medical Centre Makurdi Jos University Teaching Hospital Our Lady of Apostles Hospital Jos 8 Satellite Hospitals, 44 PHCs University of Maiduguri Teaching Hospital State Specialist Hospital Maiduguri Nursing Home Maiduguri University of Nigeria 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 Sacred Heart Catholic Hospital Lantoro University of Ibadan College of Medicine 3 Satellites under UCH Adeoyo Maternity Hospital 43 Oyo DOTS Centres Widowcare Abakiliki Ebonyi APIN Program Office Sites Under Harvard PEPFAR Sites Under APIN Ltd 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. MurphyS. Hosseini J-L SankaléH.Rawizza B. ChaplinA. Ojesina K. ScarsiK. Hurt B. Taiwo A.Dieng Sarr P. OkonkwoJ. Samuels E. EkongP. Akande T. JolayemiB. Aluko R. OlaitanS. Sagay S. OchigboO. Agbaji O. IdigbeS. Akanmu S. OgunsolaW. Gashau M. Garbati C. Okany I. AdewoleR. Nkado D. OlaleyeH. Muktar D. OwujekweJ. Abah O. EbernduN. Nulenga