1. Improving health worldwide www.lshtm.ac.uk Implications for Monitoring of the HIV Care Cascade? Jim Todd MeSH Satellite Session IAS Durban, Monday 18 th July 2016 Pathway from PMS to CBS in Tanzania

2. Rationale WHO Health Systems framework includes health informatics as one of the 6 Building Blocks Production, analysis, dissemination and use of data for information to improve the health system Regular, routine reporting of important indicators from health facility to district and national bodies (HMIS) National reporting of key indicators to international bodies Comparison across districts on performance, access to services, and finances Individual patient-level information in the facility to improve patient care and outcomes Consistent, high-quality, complete patient monitoring system (PMS) Analysis of patient data can provide important insights into epidemiology and service delivery outcomes

3. Patient-level HIV data in Tanzania Since introduction in 2004: Care and Treatment clinics (CTC) have used patient monitoring. Primary data on paper-based cards Where possible patient-level data entered into CTC database ( Similar to Tier-2 in South Africa) Periodic import of data from clinics (CTC-2) to national database (CTC-3) Analysis, use by policy makers, dissemination Care and Treatment Reports in 2010, 2013, 2016. Patient Card Clinic Record

4. WHO guidelines for HIV reporting New recommendation for test and treat (Sept 2015) MDG goals highlighted the gaps in data for reporting health indicators Gaps cannot be completely filled by surveys Realisation that regular, routine data are needed to fill these gaps UNAIDS Global AIDS reporting guidelines (2015) Concrete, time-bound targets Simple, timely annual report of key indicators National indicators should be reproducible at sub-national level WHO recommends case-based surveillance to measure progress to 90:90:90 target for HIV in all countries

5. HIV case-based surveillance (CBS) Provides longitudinal, un-duplicated data of persons diagnosed with HIV Use patient-level data from the health facility reported upwards to create indicators Accurate count along cascade beginning with diagnosis and ending with death or viral suppression Event types, and date for the event to estimate progression rates through treatment cascade May be used to estimate incidence Countries will determine the minimum set of events and indicators, example:

6. Routine CBS in Tanzania The problem in Tanzania: Aggregated non de-duplicated data used to track HIV indicators (eg numbers testing and diagnosed with HIV, ART initiation, retention) – these can be misleading Individual-based data on HIV events recommended by WHO, but not implemented in many resource-poor settings Action to find a Solution: Assess the strengths, weaknesses, opportunities and threat to current systems from the adoption of routine CBS for HIV Work out the next steps to take for implementation of CBS Strengthen estimates of the HIV continuum of care by drawing on patient level tracking systems

7. What is needed for HIV CBS? What is already present in Tanzania? Which components are missing? What works well? What needs strengthening? What is needed for a successful CBS? How can we build on the resources we have? What could go wrong?

8. Strengths, weaknesses, opportunities and threats (SWOT) Developed standardized protocol and tool Adaptable to meet country needs or focus Included engagement with stakeholder developing the tool Document (desk) review Conducted in two regions (Dar-es-Salaam and Mwanza) 23 Interviews with MoH, international, national, regional and partners staff 9 site visits to facilities including hospitals, health centres, dispensaries and laboratories Debrief with stakeholders Feedback report to MoH technical working group for implementation

9. SWOT results Strengths Substantial interest in CBS Strong foundation using existing PMS Individual identifiers used in clinics Reporting procedures in place Weaknesses Policies for CBS required Over-reliance on paper-based systems Tracking patients between clinics is difficult Data quality and use needs strengthening Opportunities Interest and funding for CBS from donors Master patient list for unique identifiers CBS data systems to build data quality & career structure for health data professionals Threats Staff and resource limitations Data feedback needed to ensure buy-in Patient confidentiality Data quality needs to be high

10. CBS in Tanzania – next steps Technical Working Group set up in MoH to develop implementation plans Improve existing routine data collection & reporting Identify the key events for CBS reporting in Tanzania Develop procedures for de-duplication and use of unique identifiers across clinics Create appropriate databases and data management systems Dissemination of SWOT results, and consultation with partners Linkage with other clinics and other diseases reported in Tanzania Train key personnel in CBS and its application

11. Conclusions Tanzanian PMS for HIV has been used since 2004, and improved at regular intervals Tier-2 combination of paper-based record, entered into local database works well in most CTC at health facilities Procedures for reporting data upwards to MoH exist and can be used for CBS There is a good basis for introducing CBS in Tanzania, through strengthening the existing systems, building on the resources and people, and utilizing the donor interest CBS must be accompanied with rigorous emphasis on data quality, and active de- duplication