1. WAD SYMPOSIUM 2014 ART Adherence and Retention: MDH Experience Eric Aris Management and Development for Health 29 th November 2014 NJOMBE

2. Outline Background Predictors of non Adherence and Retention Loss to Follow Up Retention initiative Tracking Methods Lessons Learnt and Conclusions 2

3. Background MDH supports HIV care and treatment in Dar es Salaam (DSM) since 2010 through the USG PEPFAR Fund HIV Prevalence in DSM is 6.9% higher than the national prevalence of 5.1%* DSM, HIV prev. 6.9%* 3*The Tanzania HIV/AIDS and Malaria Indicator Survey (THMIS )2012

4. Background MDH supported HIV care and treatment program:  Enrolled: 158,520 PLHIV  Initiated ART: 118,649  Current on ART: 72,977 4*The Tanzania HIV/AIDS and Malaria Indicator Survey (THMIS )2012

5. Patient Retention MDH collaborates with District/Councils health management teams (CHMTs) to improve retention among patients enrolled in HIV care and treatment Significant improvements has been noted but not to expected level (75%) Current retention rate: 68.5% Call for a need to research on new retention strategies Understanding risks associated with LTFU is key to strengthening retention strategies

6. Retention on HIV care Retention on care is crucial for early ART initiation to improve survival and quality of life of PLHIV 1 Retention of patients on HIV care and on ART is still a major challenge in SSA, including Tanzania 2 An intake of ≥ 95% of prescribed antiretroviral drug is defined as optimal adherence to ART needed to achieve sustained viral suppression 3 61: Cohen, NEJM 2011 2: Fox MP, Trop Med Int Health 2010 3: Amberbir A, BMC Public Health 2008,8:265

7. Predictors of non adherence and retention MDH conducted a study to understand the predictors of non adherence and poor retention in order to inform care and treatment program on areas that needs improvement as far as adherence and retention of patients is concerned Findings: 7

8. Flow chart 85,604 Followed from 2004 to 2011 85,604 Followed from 2004 to 2011 6,979 (8.2%) On ARV at enrolment 6,979 (8.2%) On ARV at enrolment 78,625 (91.8%) On care at enrolment 54,537 (69.4%) Initiated ARV 24,088 (30.6%) Remained on care 36,670(67.2%) initiated <60days from date of enrollment 17,867 (32.8%) initiated >60days from date of enrollment 14,248(38.8%)L TF 4,230(23.7%)LT F 5,875(16.0%) death censored 1,415(7.9%) death censored 3,387(14.0%) death censored 1,106(15.8%) death censored 2,894(41.5%)LT F 14,236(59.1%) LTF

9. Results-1 Among 85,608 patients followed, most of them were on antiretroviral therapy (ART). Significant increased risk for non adherence was found among patients with:  CD4 <100 cells/mm 3 (RR: 1.22, 95% CI 1.10 – 1.24, p=0.01);  ≥50 years of age (RR: 1.11, 95% CI 1.03 – 1.19, p< 0.0001 ) 9

10. Results-2 Among patients on care and monitoring male patients, were found to have significantly increased risk with  Advance disease stage IV (RR: 1.26, 95% CI 1.14 – 1.39, p< 0.0001)  CD4 count < 100 cells/mm 3 (RR: 2.10, 95% CI 2.07 – 2.22, p< 0.0001) respectively

11. Conclusion Patients with advance HIV/AIDS disease have significant increased risk of being LTFU The identified clinical and immunological pattern among LTFU non-ART patients correspond to the risk factors associated with HIV/AIDS mortality identified in other studies 4 This suggests possibility of AIDS mortality among the LTFU patients in programs that do not have efficient patient tracking system 114: Chalamilla et al, 2012

12. Not all “lost to follow up” are LOST September 2014, ‘Unknown’ Status exercise was done in 8 high volume Health Facilities Goal: To ascertain unknown status of patients, track and return to care Method:  List of patients with unknown status were generated  Each facility sort files, assess status and conduct tracking services  Tracking outcome were entered into CTC2 database and information shared within the facility for quality improvement Results:  Increased number of self transfer, data entry challenges, alternative treatment options/ believe, stigma by PLHIV

13. Tracking Methods

14. Not all “lost to follow up” are LOST… Amana hospital had 661 patients in the list

15. Not all “lost to follow up” are LOST… 15 Lesson learned:  Improve quality of care (Customer care services)  Designed and implement effective stigma reduction initiatives  Promote formal transfer out  Improve data management

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17. Retention initiatives Active engagement of PLHIV  Peer model  Change Agents Timely tracking services (Telephone/ Home visit)  Promise to come initiatives Community involvement in tracking services Counseling on adherence to care Use of reminder message (10 HF)

18. Involvement of PLHIV Randomized 459 PLHIV, 448 PLHIV completed training sessions Weekly 3-4hr highly interactive training sessions with CAs for 10-week covering : self-efficacy for safer sex Communication skills HIV Disclosure Relationships Values Practical focus on micro financing Importance of keeping clinic appointment

19. Achievements 19

20. Annual retention over time by district

21. Best practice for tracking services Immediate tracking services has a positive effect on return to care  Use of telephone tracking Innovation and team work increase chances of returning patients into care  Promise to come initiatives  Engagement of community health workers Effective feedback and prompt action contributes to improve quality of care  Improve customer care at reception  Improve data entry

22. Lesson learned Active engagement PLHIV in tracking and retention initiatives Improve quality of care including customer care in HF Implementation of evidenced based facility and community initiatives  Support groups  M- health Efficient data management and linkage mechanism  Proper recording and reporting  Proper linkage of patients in the database

23. Recommendations Special adherence counseling targeting patients with advance HIV disease in tandem with early ART initiation may reduce LTFU HIV Programs to design more effective patient tracking systems targeting patients in HIV care awaiting ART initiation. Further studies on effective models to improve patient retention in HIV care and treatment 23

24. Acknowledgements The govt of Tanzania through Ministry of Health and Social welfare The Dar es Salaam regional secretariat and its municipal councils health management teams Management and Development for Health staff This study has been supported by the US President’s Emergency Plan for AIDS Relief (PEPFAR) through Centers for Disease Control and Prevention under the terms of SHAPE Project Award # GH11‐112703CONT13 24

25. THANK YOU AHSANTENI SANA 25