1. ICAP Quarterly Master Slide Set January-March 2008
Purpose and audience:
The ICAP quarterly master slide set aims to summarize aggregate data that are reported every quarter across the different ICAP programs. Its primary audience is ICAP staff in country and in NY. It is not meant to be a stand alone presentation, but rather a palette of slides for people to draw on for development of tailored presentations. Staff are welcome to use the slides in their respective presentations and make stylistic changes as needed.

2. Site Census
What: Ongoing, real-time inventory of all planned, current, and closed ICAP sites. Supported activities, funding source(s) and their targets are also captured
Purpose: To have one up to date master list of sites, activities, funding sources, and targets that all ICAP staff can refer to for planning and evaluation

3. Number of ICAP-supported sites by activity, March 2008 (n=517)
Number of sites
Source: ICAP Site Census, May 2008
Take home message:
As of May 2008, ICAP supported 517 sites in 8 different program areas, i.e., care and treatment, TB screening for HIV pts, HIV testing for TB patients, PMTCT, PMTCT+, EID, PICT/VCT, and Laboratory support.
Definitions
Care and treatment:
HIV care is defined as comprehensive palliative care to pre-ART and ART patients, which includes routine follow up visits, CD4 testing, and cotrimoxazole prophylaxis for opportunistic infections. HIV treatment is defined as provision of antiretroviral treatment. Facilities only providing pediatric care and treatment should be included in this category. Programs that provide only ART prophylaxis to pregnant women or that provide care and treatment services within TB clinics should NOT be included here.
PMTCT:
PMTCT activities include, at a minimum, HIV testing in an antenatal care setting and, for HIV-infected women, provision of ARV prophylaxis. The ARV prophylaxis should be available and provided in the antenatal care setting.
PMTCT+ (subset of PMTCT sites):
PMTCT+ is defined as the provision of a more complex package of care (when compared to PMTCT above) to HIV-infected women receiving antenatal care services, including pre-screening women for ART eligibility. To be included here, the facility must offer staging and CD4 testing, provide therapeutic ART when indicated, and provide ARV prophylaxis for those not yet eligible for ART. Blood draw for CD4 testing should be performed within the antenatal care facility. Therapeutic ART can be provided in the antenatal care setting or at the HIV care and treatment facility, as long as there are documented referrals/linkages between the PMTCT and care and treatment facilities. Note that sites included in this category will be a subset of sites categorized as PMTCT sites above and those if PMTCT+ is ticked, PMTCT must also be ticked.
Early infant diagnosis:
Early infant diagnosis is defined as obtaining dried blood spots (DBS) or venous blood samples from HIV-exposed infants for DNA PCR testing. DBS can be provided in a variety of settings including antenatal care, maternal and child health (MCH) clinics, or HIV care and treatment, but to be counted as a site that provides early infant diagnosis, the sample collection must be done on-site. The processing of the sample, however, need not be done on site. Do not include this activity if HIV-exposed infants are referred off-site for DBS or venous blood collection.
TB screening among HIV patients (TB/HIV):
This category refers to screening for and diagnosis of active TB among HIV-infected patients enrolled in an ICAP-supported HIV care and treatment facility. Training of clinicians on methods of active TB screening and diagnosis and support to improve the recording of information related to this screening and diagnosis should be among the support provided.
HIV testing among TB patients (HIV/TB):
This category refers to support for HIV testing at TB treatment facilities in sites where ICAP supports the care and treatment facility. TB Model Centers directly supported by ICAP should also be included here.
Testing and counseling:
Testing and counseling includes HIV counseling and testing services offered at out-patient or in-patient departments (adult or pediatric) by clinical staff or lay staff, often referred to as PICT (Provider-initiated Counseling and Testing) or PIHCT (Provider Initiated HIV Counseling and Testing), as well as counseling and testing services offered as part of VCT. Do NOT include counseling and testing services offered in PMTCT or TB facilities.
Laboratory support:
Laboratory support is defined as the development and strengthening of laboratory facilities to support HIV/AIDS and TB-related activities. At a minimum this includes staff training and technical assistance, such as setting up infant diagnosis systems, advising on quality assurance for HIV rapid testing or for CD4 testing, and site supervision. In addition to these elements, laboratory support may include renovations, selection and procurement of equipment and commodities for chemistry analysis that are appropriate in resource limited setting. The laboratories may or may not be co-located at a site where ICAP provides other support (i.e. for care and treatment, PMTCT). Free-standing laboratories should also be included here (i.e. National Reference Laboratory in Rwanda or National Health Laboratory Services in South Africa) and added as new sites.

4. Number of ICAP-supported sites by country, March 2008 (n=571)
Number of sites
Source: ICAP Site Census, May 2008
Take home message:
ICAP supports sites in 14 different countries. Tanzania expended the number of sites from 93 to 135 sites, mainly due to the expansion of PMTCT services.

5. % care and treatment sites
Programmatic components funded at ICAP-supported care and treatment sites (n=288), March 2008
% care and treatment sites
with activity
Source: ICAP Site Census, May 2008
Take home message:
ICAP supports a wide variety of HIV-related programmatic activities beyond care and treatment. To date, TB/HIV integration appears to be the strongest linkage achieved by ICAP-83% of care and treatment sites are also receiving support on TB screening in HIV patients and 50% of the sites on HIV testing in TB patients. Laboratory support is also extensive: 60% of all care and treatment sites are also receiving laboratory support as of March 2008.
Type of activity

6. Program and Facility Characteristics Tracking System (PFaCTS)
What: Collects program and facility information on ICAP-supported care and treatment programs semi-annually
Purpose: To describe the scope, diversity, and comprehensiveness of ICAP-supported care and treatment programs, and evaluate multi-level factors that influence program performance and patient-level outcomes

7. Location and type of ICAP-supported HIV care and treatment sites (n=244)
Source: PFaCTS, January 2008
Note: Out of the 266 care and treatment sites supported by ICAP as of December 2007, 244 sites completed the PFACTS. Country breakdown is as follows: Ethiopia 38, Kenya 35, Lesotho 15, Mozambique 34, Nigeria 12, Rwanda 36, South Africa 40, Swaziland 6, Tanzania 28 sites.
Take home message:
The majority (65%; 158 out of 244) of the ICAP-supported care and treatment sites are located in urban areas.
In urban areas, the majority (91%) of sites are secondary and tertiary health facilities while in rural areas, the majority (64%) are primary health facilities.
Definitions:
Urban: Includes both urban-city, urban-other. Urban-city are areas officially designated to be a city with city administration and political bodies. Urban-other will include big and small towns, peri-urban areas, growth points, mining communities.
Rural: Includes rural-communal and rural-other. Rural-communal will include subsistence farming areas. Rural-other will include large and small scale commercial farming areas.
Instructions were given to use the category that is used by the Central Statistics Office or any other national authority that determines the official category of a location.
Primary: Health center/clinic/post usually called health center
Secondary: District/provincial hospital
Tertiary: Teaching/university/ national referral hospital.
Instructions were given to use the category used in the Health Management Information System of the Ministry of Health.

8. Proportion of ICAP-supported HIV care and treatment sites offering HIV-related services on site (n=244)
% sites with service
Source: PFaCTS, January 2008
Take home message:
Large majority (80-98%) of ICAP-supported care and treatment sites offer additional HIV-related services on-site.

9. Proportion of ICAP-supported HIV care and treatment sites offering HIV-related services on site by number of services offered (n=244)
Source: PFaCTS, January 2008
Note: Services include: VCT, TB treatment, PMTCT, Labor and delivery, and ART pharmacy.
Take home message:
The majority of ICAP-supported care and treatment sites (95%) provide all 5 HIV-related services on site. This is not surprising as the majority of ICAP-supported sites are secondary and tertiary health facilities in urban areas.

10. Proportion of ICAP-supported HIV care and treatment sites offering 5 HIV-related services on site (n=244)
ICAP Average=95%
% sites with 5 services
Source: PFaCTS, January 2008
Note: Sites that have 5 of the following on-site services are represented in the graph: VCT, TB treatment, PMTCT, Labor and delivery and ART pharmacy.
Take home message:
The majority of ICAP-supported care and treatment sites are located in sties that have other HIV-related services are offered.

11. Proportion of ICAP-supported HIV care and treatment sites offering on-site patient support services by type of service offered (n=244)
% sites with service
Source: PFaCTS, January 2008
Note: ART adherence support only includes sites that provide adherence support by trained personnel.
Take home message:
Vast majority of ICAP-supported care and treatment sites implement on-site ART adherence support services. However less than two thirds of the sites implement outreach activities, and less than a fifth implement peer educator programs for PLWHAs. Food support both to infants and to adults are also implemented in only about a fourth of our sites.
Definitions:
ART adherence support: Verbal patient education provided by trained personnel at least every 6 months
Outreach:
patients who miss clinic appointments are systematically and routinely identified and followed up in a timely fashion with phone calls or home visits
Peer educator program:
available to all patients throughout the year and meets at least monthly, includes adherence support component
Food support for infants:
Inclues milk substitution, infant formula.
Food support for adults:
includes provision of snacks, food packets

12. Proportion of ICAP-supported HIV care and treatment sites offering on-site patient support services by number of services offered (n=244)
Source: PFaCTS, January 2008
Note: Services include: ART adherence support, outreach program, peer educator program, food support for adults, and food support for infants.
Take home message:
The majority of ICAP-supported care and treatment sites (55%) only offer 1-2 patient support services, which are most commonly on-site adherence support and outreach services

13. % of sites with >=4 services
Proportion of ICAP-supported HIV care and treatment sites with ≥4 on-site patient support services (n=244)
% of sites with >=4 services
ICAP Average=17%
Source: PFaCTS, January 2008
Note: Services include: ART adherence support, outreach program, peer educator program, food support for adults, and food support for infants.
Take home message:
Availability of patient support services is highly variable across countries. It is important to note that Swaziland represents 6 sites which is significantly fewer than other countries represented here.

14. Proportion of ICAP-supported HIV care and treatment sites with access to laboratory assays (n=244)
Source: PFaCTS, January 2008
Take home message:
The large majority of ICAP-supported care and treatment site have access to HIV-related laboratory test services. For the majority of sites, CD4 evaluation is only available off site. Sixty-three percent (57%+6%) of the sites have access either on or off site ID/PCR service, and only 39% (7%+32%) of the sites have access either on or off site HIV-RNA service.

15. Proportion of ICAP-supported HIV care and treatment sites with access to laboratory assays by number of assays (n=244)
Source: PFaCTS, January 2008
Note1: Laboratory assays include: CD4, CD4 percent, HIV-RNA, early infant diagnosis, LFT, and blood chemistry.
Note2: No sites had access to all 6 laboratory test services.
Take home message:
The majority of ICAP-supported care and treatment sites have access to a comprehensive array of HIV-related laboratory test services.

16. Proportion of ICAP-supported HIV care and treatment sites with access to key HIV-related laboratory assays (n=244)
ICAP Average=86%
% sites
Source: PFaCTS, January 2008
Note: Key laboratory assays include: CD4, CD4 percent, HIV-RNA, LFT, and blood chemistry. PCR laboratory tests are excluded.
Take home message:
The majority of ICAP-supported care and treatment sites have access to core HIV-related laboratory tests through on or off site laboratory facilities.

17. Proportion of ICAP-supported HIV care and treatment sites with access to PCR laboratory assays (n=244)
ICAP Average=84%
% sites
Source: PFaCTS, January 2008
Take home message:
Across countries there is a wide range of variability in availability of PCR.

18. Number of providers per/1000 patients on ART
Mean number of health care providers per 1000 patients on ART at ICAP-supported HIV care and treatment sites (n=244)
Number of providers per/1000 patients on ART
Source: PFaCTS, January 2008
Take home message:
There is wide variability of provider to patient ratio across ICAP supported countries. Overall, 30 health care providers provide care to 1000 patients. Kenya has the highest provider to patient ratio. Note, however, this is in part due to the fact that Kenya added many small sites in recent months who do not yet have many ART patients. This artificially inflates the provider to patient ratio. (The definition of provider to patient ratio can be found below.) Health care providers include three categories of staff: physicians, health officer/medical assistants, and nurses. Nurses represent the majority of health care providers in all countries.
Definitions:
Provider to patient ratio. Numerator=number of full time health care providers; Denominator=number of patients currently on ART.

19. Number of outreach workers per/1000 patients on ART
Mean number of outreach workers per 1000 patients on ART at ICAP-supported HIV care and treatment sites (n=147)
Number of outreach workers per/1000 patients on ART
ICAP Average=11.2
Source: P-FaCTS, January 2008
Note: Sites with outreach programs only.
Take home message:
The majority of South Africa sites are primary health centers with an emphasis to bring services closer to the community. On average South Africa has the most number of outreach workers than any other country ICAP supports.

20. HIV care and treatment services

21. Sub-Saharan countries where ICAP works
Proportion of ART patients in sub-Saharan Africa that initiated ART at an ICAP-supported site, December 2006
% of all patients on ART
Source: URS, February 2008; “TOWARDS UNIVERSAL ACCESS: Scaling up priority HIV/AIDS interventions in the health sector Progress Report, April 2007” (WHO, UNAIDS, UNICEF)
Note: Overall, in Sub-Saharan Africa, 1.34 million people were on ART and 573,024 people were on ART at ICAP-supported 10 countries represented in the graph. ICAP supported 106,954 persons on ART as of December 2006.
Take home message:
Overall, ICAP supported 8% of all the ART patients in Sub-Saharan Africa as of December 2006 and 19% of ART patients in the 10 countries listed in the present slide. Coverage varies substantially by country. In Swaziland and in Mozambique, ICAP accounted for 69% and 49% of all ART patients respectively.
Sub-Saharan countries where ICAP works

22. Sub-Saharan countries where ICAP works
Proportion of ART patients in sub-Saharan Africa that initiated ART at an ICAP-supported site by sex, December 2006
% of patients on ART
Source: URS, February 2008; “TOWARDS UNIVERSAL ACCESS: Scaling up priority HIV/AIDS interventions in the health sector Progress Report, April 2007” (WHO, UNAIDS, UNICEF)
Note1: The slide represents adult patients only.
Note2: Zambia is not represented because ICAP only supports pediatric patients. Lesotho is not represented because there were no sex disaggregated data available from the USAID report.
Take home message:
Overall, ICAP supported 8% of all adult male and female ART patients in Sub-Saharan Africa as of December 2006 and 19% in the 10 countries listed in the present slide. There were no differences between the sexes. However, some differences of coverage between men and women were found at country level; in Swaziland, ICAP accounted for 77% of adult female ART patients vs. 61% of adult male ART patients.
Sub-Saharan countries where ICAP works

23. Proportion of pediatric ART patients in sub-Saharan Africa that initiated ART at an ICAP-supported site, December 2006
% of pediatric patients on ART
Source: URS, February 2008; “TOWARDS UNIVERSAL ACCESS: Scaling up priority HIV/AIDS interventions in the health sector Progress Report, April 2007” (WHO, UNAIDS, UNICEF)
Take home message:
Overall, ICAP supported 12% of pediatric ART patients in Sub-Saharan Africa as of December 2006 and 21% in the 10 countries listed in the present slide. The coverage among peds are slightly higher than coverage of adults. This is true in all countries except Lesotho, Tanzania, and Nigeria where ICAP coverage of adults is higher than peds.
Sub-Saharan countries where ICAP works

24. Proportion of adult ART patients in sub-Saharan Africa that initiated ART at an ICAP-supported site, December 2006
% of adult patients on ART
Source: URS, February 2008; “TOWARDS UNIVERSAL ACCESS: Scaling up priority HIV/AIDS interventions in the health sector Progress Report, April 2007” (WHO, UNAIDS, UNICEF)
Note: Zambia was not included because Zambia is not represented because ICAP only supports pediatric patients.
Take home message:
Overall, ICAP supported 12% of pediatric ART patients in Sub-Saharan Africa as of December 2006 and 21% in the 10 countries listed in the present slide. The coverage among peds are slightly higher than coverage of adults. This is true in all countries except Lesotho, Tanzania, and Nigeria where ICAP coverage of adults is higher than peds.
Sub-Saharan countries where ICAP works

25. Cumulative enrollment at ICAP-supported HIV care and treatment programs (ever-supported)
Cameroon,
Cote d’Ivoire,
Kenya,
Lesotho,
Rwanda,
S. Africa,
Tanzania
Uganda,
Thailand
Nigeria,
Swaziland,
Zambia
Ethiopia
Number of patients
458, in care
Mozambique
Number of facilities
Source: ICAP URS, May 2008
Note: Includes all transitioned sites with data carried over.
Take home message:
ICAP is expanding rapidly adding country programs every year. To date, ICAP has supported 458,025 patients with HIV care and 213,549 patients with ART care.
213,549 on ART

26. Cumulative pediatric enrollment in ICAP-supported HIV care and treatment programs (ever-supported)
303 sites
Nigeria,
Swaziland,
Zambia
Cameroon,
Cote d’Ivoire,
Kenya,
Lesotho,
Rwanda,
S. Africa,
Tanzania
Uganda,
Thailand
52,455 in care
Ethiopia
Number of facilities
Number of patients
Mozambique
Source: ICAP URS, May 2008
Note: Includes all transitioned sites with data carried over.
Take home message:
ICAP emphasizes enrolment of HIV-infected children in HIV care and ART care. As with overall enrolment figure, enrolment of pediatric patients have increased over the past three years. Pediatric cases represent about 11% of HIV care patients and 8% of ART patients.
17,961 on ART

27. Cumulative enrollment in ICAP-supported HIV care and treatment programs (currently supported)
Nigeria,
Swaziland,
Zambia
393,707 in care
Cameroon,
Cote d’Ivoire,
Kenya,
Lesotho,
Rwanda,
S. Africa,
Tanzania
Uganda,
Thailand
258 sites
Ethiopia
Number of facilities
Number of patients
Mozambique
178,985 on ART
Source: ICAP URS, May 2008
Note: Excludes all transitioned sites after transition.
Take home message:
ICAP is expanding rapidly adding country programs every year. To date, among the currently supported sites, ICAP supports 393,707 patients with HIV care and 178,985 patients with ART care.

28. Cumulative pediatric enrollment in ICAP-supported HIV care and treatment programs (currently supported)
Nigeria,
Swaziland,
Zambia
39,124 in care
Cameroon,
Cote d’Ivoire,
Kenya,
Lesotho,
Rwanda,
S. Africa,
Tanzania
Uganda,
Thailand
Ethiopia
262 sites
Number of facilities
Number of patients
Mozambique
15,153 on ART
Source: ICAP URS, May 2008
Note1: Excludes all transitioned sites.
Take home message:
ICAP emphasizes enrolment of HIV-infected children in HIV care and ART care. As with overall enrolment figure, enrolment of pediatric patients have increased over the past three years. Among the sites currently being supported by ICAP, pediatric cases represent about 10% of HIV care patients 8% of ART patients.

29. Current and target cumulative enrollment in ICAP-supported care and treatment programs
Number of patients
Source: ICAP URS, May 2008
Note1: Targets available for MCAP countries, including Cote d’Ivoire, Ethiopia, Kenya, Mozambique, Nigeria, Rwanda, South Africa and Tanzania.
Note2: The targets are COP08 targets, i.e., October-September program cycle.
Take home message:
As of the end of December, MCAP funded ICAP programs have made good progress toward the COP08 targets; 89% of HIV care and 77% of ART targets have been met.

30. Current and target cumulative HIV care enrollment in ICAP-supported care and treatment programs by country
93% of target
97% of target
90% of target
Number of patients
74% of target
110% of target
51% of target
1% of target
76% of target
Source: ICAP URS, May 2008
Note: Targets available for MCAP countries, including Cote d’Ivoire, Ethiopia, Kenya, Mozambique, Nigeria, Rwanda, South Africa and Tanzania.
Take home message.
As of the end of December, MCAP funded ICAP programs have made good progress toward the COP08 HIV care targets.

31. Current and target cumulative ART enrollment in ICAP-supported care and treatment programs by country
79% of target
89% of target
88% of target
37% of target
104% of target
Number of patients
87% of target
73% of target
2% of target
Source: ICAP URS, May 2008
Note: Targets only available for MCAP countries, including Cote d’Ivoire, Ethiopia, Kenya, Mozambique, Nigeria, Rwanda, South Africa and Tanzania.
Take home message.
As of the end of December, MCAP funded ICAP programs have made good progress toward the COP08 ART care targets.

32. Cumulative enrollment in HIV care in ICAP-supported HIV care and treatment programs by country (n=393,707)
Number of patients
Source: ICAP URS, May 2008
Includes data from sites currently supported by ICAP.
Take home message:
This slide shows the number of patients enrolled in HIV care over time by country. Mozambique enrolled the highest number of patients in HIV care among the 10 country programs supported by ICAP.

33. Cumulative enrollment on ART at ICAP-supported HIV care and treatment programs by country (n=178,985)
Number of patients
Source: ICAP URS, May 2008
Take home message:
This slide shows the number of patients enrolled in ART care over time by country. Mozambique enrolled the highest number of patients in ART care among the 10 country programs supported by ICAP.

34. Cumulative and current enrollment in ART care at ICAP-supported HIV care and treatment programs (n= 165,495*)
Lost to follow up
Cumulative initiating ART
Reported dead
Number of patients
Source: ICAP URS, May 2008
Take home message:
A large majority of ART patients are retained in HIV care. Lost to follow up is defined as those patients who have not returned to the clinic for more than 90 days. Documentation of outcomes is poor at some facilities and is being addressed through implementation of data quality assurance SOPs.
ART patients retained in care
ART patients retained in care
* Excludes Zambia and Swaziland as no follow up data were reported for ART patients

35. Cumulative enrollment in ICAP-supported HIV care and treatment programs by ART status, age, and sex
Total care enrollment (n=393,707)
Total ART enrollment (n=178,985)
Source: ICAP URS, May 2008
Take home message:
This slide shows enrollment data broken out by sex and age. Enrollment in care, including ART care, continues to increase in women, men, and children. Among adults, females represent the majority of persons enrolled.

36. % patients initiating ART
Proportion of patients ever enrolled in HIV care who initiated ART in ICAP-supported care and treatment programs as of March 2008
% patients initiating ART
Source: ICAP URS, May 2008
Take home message:
Overall, 45% of patients enrolled in HIV care are also in ART care. The proportion of patients who are in ART care varies substantially from country to country and is greatest in Cote d’Ivoire and South Africa , where the majority are in ART care.
n=22,175
N=41,445
n=381,782*
n=194
n=50,019
n=34,006
n=26,563
n=52,482
n=26,478
n= 7,304
n=121,116
* Excludes Swaziland as no HIV care data were reported

37. Cumulative enrollment in ICAP-supported HIV care and treatment programs by age and sex as of March 2008
n=214,722
n=167,060
n=381,782*
% patients
Source: ICAP URS, May 2008
Take home message:
A large majority of patients enrolled in ICAP-supported HIV care and treatment programs are women. The higher proportion of men among ART patients relative to pre-ART patients probably reflects the fact that males tend to present at a more advanced stage of HIV disease and are therefore more likely than females to be eligible for ART.
* Excludes Swaziland as no HIV care data were reported

38. Cumulative HIV care enrollment of women and children in ICAP-supported HIV care and treatment programs as of March 2008
% patients in HIV care
Source: ICAP URS, May 2008
Take home message:
The patient population varies across ICAP-supported countries, reflecting differences in the epidemic as well as differences in entry points. Overall, 10% of our patient population are children under 15. Note that in Zambia ad Rwanda, the proportion of children is driven by the Pediatric Centers of Excellence. The proportion in regular sites are lower.
n=381,782*
n=26,563
n=7,304
n=194
n=26,478
n=22,175
n=52,482
n=50,019
n=41,445
n=34,006
n=121,116
* Excludes Swaziland as no HIV care data were reported

39. Cumulative ART enrollment by women and children in ICAP-supported HIV care and treatment programs as of March 2008
% patients on ART
Source: ICAP URS, May 2008
Take home message:
The patient population varies across ICAP-supported countries, reflecting differences in the epidemic as well as differences in entry points. Overall, 8% of our patient population are children under 15. Note that a smaller proportion of children (8% v.s. 10%) are on ART, likely reflecting difficulties making diagnosis of HIV infection in children.
n=17,558
n=178,985
n=113
n=9,649
n=12,601
n=17,979
n=10,677
n=28,354
n=28,818
n=1,565
n=11,925
n=39,748

40. % pediatric patients in HIV care
Cumulative pediatric HIV care enrollment in ICAP-supported HIV care and treatment programs
as of March 2008
n=38,278*
n=5,788
n=2,085
n=11,249
n=3,397
n=859
n=4,419
n=1,973
n=4,833
n=3,666
n=9
% pediatric patients in HIV care
Source: ICAP URS, May 2008
Take home message:
Large majority of pediatric patients receiving HIV care were under 5 year of age (60%). In Zambia and in Nigeria, the majority of pediatric patients were under 1. In Lesotho, Kenya, and Tanzania, however, the majority were 5-14 years of age.
* Excludes Swaziland as no pediatric breakdown were reported

41. % pediatric patients on ART
Cumulative pediatric ART enrollment in ICAP-supported HIV care and treatment programs
as of March 2008
n=14,307*
n=517
n=3,419
n=1,499
n=439
n=2,157
n=1,677
n=860
n=1,905
n=1,830
n=4
% pediatric patients on ART
Source: ICAP URS, May 2008
Take home message:
There is large variability for proportion of <1 year enrolled across countries. This is likely a reflection of the variation in the availability of early infant diagnosis. Note that the proportion of patients <1 year in ART care is about half of that in pre-ART (19% v.s. 36% from previous slide).
* Excludes Swaziland as no pediatric breakdown were reported

42. % patients eligible for ART
ART initiation among patients eligible for ART in ICAP-supported HIV care and treatment programs, Jan-March 2008 (n=24,074)
n=24,074
n=5,235
n=2,163
n=2,663
n=4,975
n=2,346
n=1,514
n=3,280
n=1,784
n=114
% patients eligible for ART
Source: ICAP URS, May 2008
Note: Data not available for Swaziland and Zambia.
Take home message:
Overall 20% of those eligible for ART care were not started on ART. South Africa has the highest number of eligible patients not initiating ART closely followed by Tanzania.
Definitions:
Eligible, but not started: Sites report “number in HIV care during the quarter and eligible for ART but NOT started ART by the end of the quarter.”
Eligible, started: All those who were eligible and started on ART during the reporting quarter.

43. ART regimens distributed to adults in ICAP-supported HIV care and treatment programs,
January-March 2008
Overall
n=109,790
Cote d’Ivoire
n=108
Ethiopia
n=18,141
Kenya
n=9,759
Lesotho
n=5,465
Moz
n=28,029
Nigeria
n=8,220
Rwanda
n=11,126
South Africa
n=19,988
Tanzania
n=8,954
1st line regimen
d4T-3TC-NVP
57,574
(52%) 67
(62%)
9,758
(54%)
8,103
(83%)
2,954
19,856
(71%)
3,127 (38%)
4,647
(42%)
2,565
(13%)
6,497
(73%)
d4T-3TC-EFV
26,402
(24%) 32
(30%)
3,796
(21%)
1,025
(11%)
944
(17%)
2,354
(8%)
191
(2%)
832
(7%)
16,179
(81%)
1,049
(12%)
ZDV-3TC-NVP
15,338
(14%) 6
(6%)
2,977 (16%)
345
(4%)
925
1,436
(5%)
4,615
(56%)
4,009 (36%)
192
(1%)
833
(9%)
ZDV-3TC-EFV
5,478
(0%)
1,510
130
527
(10%)
564
287
(3%)
1,097
800
563
2nd line regimen
1,853 2 97
(.5%)
120
115
779
541 5%
187 12
Unknown regimen
3,145 1 3 36
3,040 65
Source: ICAP URS, May 2008
Note1: Data not available for Swaziland and Zambia.
Note2: The numbers represent patients currently on ART (not cumulative on ART represented in previous slides).
Take home message:
Large majority of patients enrolled in ICAP-supported HIV care and treatment programs are on 1st line regimens. Very few (2%) are on 2nd line regimen. Regimen information appears to be poorly recorded in Mozambique where regimen information was not available for about 11% of the patients. Also, overwhelming majority of patients are on just a few (3) first line regimens, reflecting the public health approach to ART scale-up.

44. ART regimens distributed to children in ICAP-supported HIV care and treatment programs, January-March 2008
Overall
n=10,215
Cote d’Ivoire
n=4
Ethiopia
n=1,317
Kenya
n=1,291
Lesotho
n=237
Moz
n=2,839
Nigeria
n=410
Rwanda
n= 1,471
South Africa*
n=1,970
Tanzania
n=676
1st line regimen
d4T-3TC-NVP
2,852
(28%) 2
(50%)
291
(22%)
500
(39%)
113
(48%)
995
(35%) 25
(6%)
607
(41%) 41
(2%)
278
d4T-3TC-EFV
1,910
(19%)
102
(8%)
197
(15%)
(17%)
103
(4%) 24
129
(9%)
1,288
(65%) 26
ZDV-3TC-NVP
2,654
(26%)
770
(58%)
473
(37%) 61
218
288
(70%)
497
(34%) 29
(1%)
318
(47%)
ZDV-3TC-EFV
805
142
(11%) 96
(7%) 13
(5%)
(0.5%) 73
(18%)
198
(13%)
214 54
Other*
331
(3%)
(0%)
2nd line regimen
149 1 8 70 12 58
Unknown regimen
1,845 11 17 9
1,440
(51%) 28
Source: ICAP URS, May 2008
Note1: Data not available for Swaziland and Zambia.
Note2: In South Africa, d4T-3TC-LPV/r is also prescribed as a first-line regimen for pediatric patients.
Take home message:
Large majority of pediatric patients enrolled in ICAP-supported HIV care and treatment programs are on 1st line regimens. Very few (1%) are on 2nd line regimen. Regimen information is poorly recorded in Mozambique where regimen information was not available for about 51% of the patients. Also, overwhelming majority of patients are on just a few (3) first line regimens, reflecting the public health approach to ART scale-up.

45. % patients with CD4 count
Proportion of patients with CD4 count at baseline, 6, and 12 months after ART initiation, as of March 2008
% patients with CD4 count
Source: ICAP URS, May 2008
Note1: Baseline data is weighted average of matched 6 and 12 month cohort data at baseline
Note2: Data not available for Swaziland and Zambia.
Note 3:
Number of matched cohorts by country:
Ethiopia: 132
Kenya:  104
Lesotho:  14
Mozambique:  106
Nigeria:  9
Rwanda:  141
South Africa:  67
Tanzania:  31
TOTAL:  604
Take home message:
There is substantial variability between countries. The baseline CD4 completeness appears to be good for South Africa, Rwanda, Ethiopia, Lesotho but it is lower in Kenya, Moz, Nigeria, and particularly Tanzania. Follow-up CD4 completeness is concerning. Overall, 49% and 45% of the patients in the cohorts had 6 months and 12 months follow up evaluations, respectively.

46. Average median CD4 count at baseline and 6 and 12 months after ART initiation, as of March 2008
Source: ICAP URS, May 2008
Note1: Baseline CD4 count is weighted average of baseline count for matched 6 and 12 month cohorts
Note2: Data not available for Swaziland and Zambia
Note 3:
Number of matched cohorts by country:
Ethiopia: 132
Kenya:  104
Lesotho:  14
Mozambique:  106
Nigeria:  9
Rwanda:  141
South Africa:  67
Tanzania:  31
TOTAL:  604
Take home message:
Significant increase in CD4 count is recorded among ART patients from baseline, 6 months to 12months. Note that there is high proportion of missing follow-up cd4 counts as shown in the previous slide. Potential biases in interpreting the follow-up CD4 counts because they represent as few as 14% (Nigeria) of patients in the cohort
Definitions:
Baseline CD4 = weighted average of baselines from 6-mo and 12-mo cohorts.
6-Mo CD4 = weighted average of median CD4 at 6-mo.
12-Mo CD4 = weighted average of median CD4 at 12-mo.

47. Change in median CD4 count
Change in Median CD4 count (cells/µL) at 6 and12 months of ART, as of March 2008
Change in median CD4 count
Source: ICAP URS, May 2008
Note: Data not available for Swaziland and Zambia.
Note 3:
Number of matched cohorts by country:
Ethiopia: 132
Kenya:  104
Lesotho:  14
Mozambique:  106
Nigeria:  9
Rwanda:  141
South Africa:  67
Tanzania:  31
TOTAL:  604
Take home message:
CD4 change between baseline and at 6 months vary across countries from 161 in Nigeria to 100 in Rwanda. CD4 change between baseline and at 12 months varies more from 188 in Lesotho to 142 in Rwanda.

48. Status of ART patients at ICAP-supported HIV care and treatment programs as of March 2008 (n=165,495*)
Lost to
follow-up
62%
119.2 per 1,000 person-years
71.0 per 1,000 person-years
Source: ICAP URS, May 2008
Note1: Excludes patients who transferred out and unknowns.
Take home message:
Among those discontinued ART (18%), the majority (62%) had missed a scheduled clinic visit by more than 90 days (Lost to follow up), 34% had been reported dead and 5% stopped treatment due to complications.
Person time:
ART discontinuation per 1000 person years can capture the time element that is not captured by cumulative discontinuation rate reported each quarter. Two sites may have the same cumulative discontinuation rate at 20% but one site may have started providing ART 6 months ago while the other site may have started 2 years ago. Calculating the rate in person-time will show that the first site is losing patients at a greater rate than in the second site. Below, is a step-by-step explanation of how the rates were calculated:
A. Assume patients starting ART on average started at “mid-point” of the quarter (i.e., at 1.5 months).
100 patients started on ART during the quarter are assumed to have contributed 100 persons x 1.5 months or 150 person-months on ART during the quarter
B. Number on ART at the beginning of the quarter is used to calculate the number of person-years of ART use that could be contributed if there were no deaths, transfers, stopping, or LTF during the quarter.
500 patients enrolled as of the end of the previous quarter are assumed to contribute 500 persons x 3 months, or 1500 person-months of ART during the quarter
C. Patients who stop ART during the quarter
Patients who stop ART (die, transfer, are LTF, or otherwise stopped ART) are assumed to have done so at the midpoint of the quarter.
35 people stop ART for any of the above reasons, they are assumed to contribute 35 persons x 1.5 months, or about 82 person-months.
This person time must be subtracted from that in B in order to correct for the assumption of no stoppages during the quarter.
Person-time on ART during the quarter= A + (B – C)= =1568 pm
Reported
dead 34%
9.4 per 1,000 person-years
Stopped ART 5%
* Excludes Zambia and Swaziland as no follow up data were reported for ART patients

49. Reasons for ART discontinuation in ICAP-supported HIV care and treatment programs as of March 2008
% patients
Source: ICAP URS, May 2008
Note: Excludes patients who transferred out.
Take home message:
As explained in the previous slide, the majority of those who discontinued ART were lost to follow up. In Kenya and Lesotho, the proportion of lost to follow up among all those have discontinued treatment were very high at 86% and 80%.

50. Person-years on ART and discontinuation rates at ICAP-supported care and treatment programs
Cumulative events per 1,000 person-years
Cumulative person-years on ART
Source: ICAP URS, May 2008
Note: Data not available for Swaziland and Zambia
Take home message:
ICAP supported care and treatment programs have accumulated over 130,000 cumulative person-years of experience on ART at the end of the January – March 2008 reporting quarter. Known deaths and lost to follow up vary widely between quarters but appear to be increasing over the quarter. The variation across quarters are probably due to new sites being added. Patients from new sites will contribute more person-years on ART (denominator) but would have not contributed to the cumulative number of events (numerator).
Definitions:
Cumulative person years on ART is calculated as the cumulative number of patients on ART by time they have been on ART. The cumulative number of events per 1000 person-years is calculated as the number of events, i.e., lost to follow up and deaths, in the numerator and cumulative number of person-years in the denominator. Please refer to slide 45 for how rates are calculated.

51. PMTCT services

52. Pregnant women counseled and tested in ICAP-supported PMTCT programs, April-Dec 2007
Number of women
Source: ICAP URS, February 2007
Note: 165 sites in Ethiopia, Lesotho, Mozambique, Nigeria, Rwanda
Take home message:
Overall, ICAP has counseled and tested over 100,000 pregnant women in 9 months of ,175 were found HIV positive and 4,871 were subsequently given ART prophylaxis.

53. Pregnant women counseled and tested in ICAP-supported PMTCT programs April-Dec 2007
Number of women
Source: ICAP URS, February 2007
Note: % counseled and % tested are both using 1st ANC visit as the denominator.
Take home message:
Overall, ICAP has counseled and tested over 100,000 pregnant women in 9 months of ICAP counseled and tested most pregnant women coming for their 1st ANC visit at an ICAP supported pmtct site. ART prophylaxis is however given to only two thirds of those who were HIV positive. However as you will see below, the trend is positive.

54. Pregnant women counseled and tested in ICAP-supported PMTCT programs over time
Number of women
Source: ICAP URS, February 2007
Take home message:
Overall, number of women counseled and tested increasing dramatically as we take on a large number of new sites.

55. Pregnant women counseled and tested in ICAP-supported PMTCT programs over time
Number of women
Source: ICAP URS, February 2007
Note: % counseled and % tested are both using 1st ANC visit as the denominator.
Take home message:
Proportion of women attending first ANC and testing is increasing. Seroprevalence rate is similar between quarters (8.4% in Q1; 6.5% in Q2). But proportion of positive women who receive ART prophylaxis has increased from 47% to 59% between Q1 and Q2.
n=33,648
n=38,727
n=50,313

56. Pregnant women counseled and tested in ICAP-supported PMTCT programs by country, April-Dec 2007
Source: ICAP URS, February 2007
Take home message:
Most women who come for their first ANC visit get counseled about HIV and tested. Difficult to see in this slide because of the Y-axis scale, but more than half of infected women received ART prophylaxis. Problems in accurately recording when prophylaxis given lead to underestimates of prophylaxis coverage in ANC.
*More women were counseled than attending 1st ANC because some of the sites cannot distinguish between counseling and testing done at first ANC visit vs. a follow-up visit.

57. Type of ART prophylaxis at ICAP-supported PMTCT programs, April-December 2007
n=5,406
n=274
n=535
n=2,414
n=1,610
n=472
n=101
% women
Source: ICAP URS, February 2007
Take home message:
Programs are starting to introduce more complex regimens than sd-NVP and among pregnant women who are eligible. ***Note: this slide does NOT include women who started HAART during pregnancy. Only HAART as prophylaxis which is only offered as part of national regimen in Rwanda and Nigeria.
Note: AZT/sd-NVP category also includes women who received AZT/3TC tail postpartum

58. TB/HIV services

59. Proportion of HIV patients screened, screened positive and initiated TB treatment in ICAP-supported care and treatment programs as of March 2008
% patients
Source: ICAP URS, May 2008
Note: Overall 189 sites contributed data. Country breakdown is as follows: Ethiopia 39, Kenya 34, Mozambique 24, Nigeria 18, Rwanda 43, Tanzania 31 sites. Ethiopia only reports the first indicator in the cascade and only includes data from October 2007 to March South Africa did not report any data this quarter but reported numbers in the past. Therefore it is represented in this cumulative slide.
The first (green) bar represents the proportion of newly-enrolled HIV patients screened for TB at enrollment.
The second (aqua) bar represents the proportion of screened patients who screened positive for TB.
The third (blue) bar represents the proportion of patients with a positive screen who initiated TB treatment.
Take home message:
In Nigeria, Kenya and Mozambique, the proportion of patients screened for TB upon enrollment is well below our target of >90%.
New HIV patients
n=94,732
n=1,097
N=11,897
n=11,244
n=18,007
n=14,618
n=26,341

60. Proportion of TB patients HIV tested, tested positive and started HIV care at ICAP-supported TB treatment programs as of January 2008
% patients
Source: ICAP URS, February 2007
Note: Overall 145 sites contributed data. (Eth 39, Kn 2, Mz 21, Ng 39, SA 2, Tz 26 sites). Rwanda and Tanzania do not report numbers from the TB clinic. South Africa only reports data from 2 TB hospitals. Kenya was only able to collect data from 2 sites.
In Nigeria, Ethiopia, and South Africa, the first bar represents the proportion of new TB patients with an unknown HIV status who were HIV tested at the TB clinic upon enrollment.
In Mozambique and Kenya, the first (green) bar represents those new TB patients who were HIV tested at any site.
Take home message:
In Mozambique and South Africa, a significant number of new enrollees in TB treatment programs were not HIV tested at enrollment. In Nigeria, by contrast, most new TB patients were HIV tested. In Kenya many people who tested positive for HIV did not subsequently enroll in HIV care and treatment programs. In South Africa, because HIV care and treatment services are available at the TB hospitals, the proportion is 99%.
New TB patients
n=38,489
n=3,453
n=3,911
n=25,073
n=3,061
n=2,894

61. Proportion of newly enrolled HIV patients screened for TB at enrollment over time in ICAP-supported care and treatment programs
Source: ICAP URS, May 2008
Note: Ethiopia is excluded from all quarters, as it only reports # screened and not the rest of the cascade.
Take home message:
Although TB screening at enrollment into HIV care is an ICAP standard of care, significant numbers of new enrollees were not screened (or the screening was not recorded). There has been a slow but steady increase in the number of newly enrolled HIV patients screened for TB at enrollment. We remain, however, well below our target of >90%.
New HIV patients
n=8,685
n=13,950
n=17,563
n=24,484
n=30,050

62. Proportion of new TB patients tested for HIV over time in ICAP-supported TB treatment programs
Source: ICAP URS, May 2008
Note: Rwanda and Tanzania are excluded from the analysis, as they have stopped reporting HIV testing numbers.
Take home message:
Although HIV testing TB patients with an unknown HIV status at enrollment is an ICAP standard of care, we remain below our target of >90%.
New TB patients
n=7,444
n=6,921
n=7,514
n=7,381

63. Counseling and Testing services

64. Cumulative number of individuals who received counseling and testing for HIV at ICAP-supported HIV care and treatment programs, as of March 2008
Source: ICAP January-March 2008 Quarterly Narrative Report, May 2008
Take home message:
Overall, ICAP has counseled and tested 442,143 individuals in Ethiopia, Nigeria, and Rwanda as of January 2008 both through Provider-Initiated and Voluntary Counseling and Testing services. These numbers exclude counseling and testing provided at TB and PMTCT clinics.