1. Number of ICAP-supported sites by activity, January 2009 (n=711)
Number of sites
Source: ICAP Site Census, January 2009
Take home message:
As of January 2009, ICAP supported 711 sites in 7 different program areas, i.e., care and treatment, TB screening for HIV pts, HIV testing for TB patients, 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.

2. Number of ICAP-supported sites by country, January 2009 (n=711)
Number of sites
Source: ICAP Site Census, January 2009
Take home message:
ICAP supports sites in 14 different countries. Tanzania further expended the number of sites from 188 to 237 sites, mainly due to the expansion of PMTCT services.

3. 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

4. Location and type of ICAP-supported HIV care and treatment sites (n=296)
Source: PFaCTS, June 2008
Note: There were 303 sites supported by ICAP in Jan-March 2008 and 362 in April-June 2008; 349 sites completed the PFACTS (there is incomplete data on site location and site type for some). Country breakdown is as follows: Cote D’Ivoire 9, Ethiopia 45, Kenya 71, Lesotho 23, Mozambique 40, Nigeria 27, Rwanda 44, South Africa 37, Swaziland 6, Tanzania 45 sites.
Take home message:
The majority (56%; 166 out of 296) of the ICAP-supported care and treatment sites are located in urban areas.
In urban areas, the majority (69%) of sites are secondary and tertiary health facilities while in rural areas, the majority (72%) 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.

5. Proportion of ICAP-supported HIV care and treatment sites offering HIV-related services on site (n=303)
% sites with service
Source: PFaCTS, June 2008
Take home message:
Large majority (77-100%) of ICAP-supported care and treatment sites offer additional HIV-related services on-site.

6. Proportion of ICAP-supported HIV care and treatment sites offering HIV-related services on site by number of services offered (n=284)
Source: PFaCTS, June 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 (73%) 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.

7. Proportion of ICAP-supported HIV care and treatment sites offering ≥4 HIV-related services on site (n=257)
ICAP Average=99%
% sites with ≥4 services
Source: PFaCTS, June 2008
Note: Sites that have >=4 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 sites that have other HIV-related services are offered.

8. Proportion of ICAP-supported HIV care and treatment sites offering on-site patient support services by type of service offered (n=303)
% sites with service
Source: PFaCTS, June 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 third implement peer educator programs for PLWHAs. Food support to children/infants is implemented in about one third of sites, food support to adults is 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 children/infants:
Inclues milk substitution, infant formula; nutritional treatment for severely malnourished children.
Food support for adults:
includes provision of snacks, food packets

9. Proportion of ICAP-supported HIV care and treatment sites offering on-site patient support services by number of services offered (n=248)
Source: PFaCTS, June 2008
Note: Services include: ART adherence support, outreach program, peer educator program, food support for adults, and food support for children/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

10. % of sites with ≥ 4 services
Proportion of ICAP-supported HIV care and treatment sites with ≥4 on-site patient support services (n=248)
% of sites with ≥ 4 services
ICAP Average=29%
Source: PFaCTS, June 2008
Note: Services include: ART adherence support, outreach program, peer educator program, food support for adults, and food support for children/infants.
Take home message:
Availability of patient support services is highly variable across countries. It is important to note that Swaziland represents x sites which is significantly fewer than other countries represented here.

11. Proportion of ICAP-supported HIV care and treatment sites with access to laboratory assays (n=303)
Source: PFaCTS, June 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. Eighty-eight percent (83%+5%) of the sites have access either on or off site ID/PCR service, and only 39% (6%+33%) of the sites have access either on or off site HIV-RNA service.

12. Proportion of ICAP-supported HIV care and treatment sites with access to laboratory assays by number of assays (n=300)
Source: PFaCTS, June 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.

13. Proportion of ICAP-supported HIV care and treatment sites with access to key HIV-related laboratory assays (n=277)
ICAP Average=92%
% sites
Source: PFaCTS, June 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.

14. Proportion of ICAP-supported HIV care and treatment sites with access to PCR laboratory assays (n=283)
ICAP Average=90%
% sites
Source: PFaCTS, June 2008
Take home message:
Across countries there is a wide range of variability in availability of PCR.

15. 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=303)
Number of providers per/1000 patients on ART
Source: PFaCTS, June 2008
Take home message:
There is wide variability of provider to patient ratio across ICAP supported countries. Overall, 79 health care providers provide care to 1000 patients on ART. Kenya has the highest 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.

16. 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=163)
ICAP Average=6.9
Number of outreach workers per/1000 patients on ART
Source: P-FaCTS, June 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.

17. Trend in proportion of ICAP-supported HIV care and treatment sites offering on-site patient support services (n=170)
Source: PFaCTS, June 2008
Note: Only sites that answered for all rounds of data collection individually for each question were included in the analysis (e.g. only sites that answered about outreach in each round are included in the three bars of results for outreach).
Take home message: Among sites that completed PFaCTS in Jan 07, July 07, and Jan 08 there is an increase in the proportion of sites offering food support for adults, food support for adults or infants, outreach programs, adherence support or peer educator programs. 17

18. Trend in proportion of ICAP-supported HIV care and treatment sites offering prevention services (n=224)
Counseling regarding disclosure
Education on behavior and safe sex
Provision of condoms
Referral for on-site screening for STIs
Education on high-risk substance use
Screening for drug and alcohol abuse
Source: PFaCTS, June 2008
Note: Only sites that answered for all rounds of data collection individually for each question were included in the analysis (e.g. only sites that answered about counseling in each round are included in the three bars of results for outreach).
Take home message: Among sites that completed PFaCTS in July 07, and Jan 08 there is an increase in the proportion of sites offering counseling regarding disclosure, education on behavior and safe sex, education on high-risk substance abuse, and screening for drug and alcohol abuse. There was a slight decrease in the reporting of sites that provide condoms and refer for screening for STIs which could reflect changes in programs or incorrect reporting of activities. 18

19. Sub-Saharan countries where ICAP works
Proportion of ART patients in sub-Saharan Africa that initiated ART at an ICAP-supported site, December 2007
% of all patients on ART
Source: URS, August 2008; “Estimated number of people receiving antiretroviral therapy, December 2007” (The Henry J. Kaiser Foundation, globalhealthfacts.org)
Note: Overall, in Sub-Saharan Africa, 2,12 million people were on ART and 1.4 million people were on ART at ICAP-supported 10 countries represented in the graph. ICAP supported 190,147 persons on ART as of December 2007.
Take home message:
Overall, ICAP supported 9% of all the ART patients in Sub-Saharan Africa as of December 2007 and 14% of ART patients in the 10 countries listed in the present slide. Coverage varies substantially by country. In Swaziland, Lesotho, and Mozambique, ICAP accounted for 48%, 40%, and 39% of all ART patients respectively.
Sub-Saharan countries where ICAP works

20. HIV care and treatment services
HIV patients ever enrolled in ICAP supported sites (including closed sites)
HIV patients ever initiating ART in ICAP supported sites (including closed sites)
590,151
270,780

21. Cumulative enrollment in ICAP-supported HIV care and treatment programs (currently reporting)
390 sites
Lesotho,
Rwanda,
S. Africa,
Tanzania
Nigeria,
Zambia
519,665 in care
Ethiopia
Number of facilities
Number of patients
Mozambique
235,746on ART
Source: ICAP URS, February 2009
Note1: Includes sites currently supported by ICAP and reporting.
Note2: Swaziland is excluded.
Take home message:
ICAP is expanding rapidly adding country programs every year. To date, among the currently supported sites, ICAP supports 519,665 patients with HIV care and 235,746 patients with ART care.

22. Cumulative pediatric enrollment in ICAP-supported HIV care and treatment programs (currently reporting)
390 sites
Cote d’Ivoire
Nigeria,
Zambia
53,897 in care
Ethiopia
Mozambique
Number of facilities
Number of patients
Lesotho,
Rwanda,
S. Africa,
Tanzania
22,103 on ART
Source: ICAP URS, February 2009
Note1: Includes sites currently supported by ICAP and reporting.
Note2: Swaziland is excluded.
Note3: Zambia was unable to report Jan-Mar 08 quarter. Oct-Dec 07 numbers were 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. To date 53,897 pediatric patients were in care (10% of all patients) and 22,103 of them were on ART (9% of all patients).

23. Cumulative enrollment in HIV care in ICAP-supported HIV care and treatment programs by country (n= 519,665)
Number of patients
Source: ICAP URS, February 2009
Note: Includes sites currently supported by ICAP and reporting.
Note2: Swaziland is excluded.
Note3: Zambia was unable to report Jan-Mar 08 quarter. Oct-Dec 07 numbers were carried over.
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. 23

24. Cumulative enrollment on ART at ICAP-supported HIV care and treatment programs by country (n=235,746)
Zambia
Number of patients
Kenya
Source: ICAP URS, February 2009
Note: Includes sites currently supported by ICAP and reporting.
Note2: Swaziland is excluded.
Note3: Zambia was unable to report Jan-Mar 08 quarter. Oct-Dec 07 numbers were carried over.
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. 24

25. Person-years on ART at ICAP-supported care and treatment programs
Cumulative events per 1,000 person-years
Cumulative person-years on ART
Source: ICAP URS, February 2009
Note: Data not available for Swaziland and Zambia
Take home message:
ICAP supported care and treatment programs have accumulated over 291,982 cumulative person-years of experience on ART at the end of the October-December 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.

26. Cumulative initiating ART ART patients retained in care
Cumulative and current enrollment in ART care at ICAP-supported HIV care and treatment programs (n= 235,746)
Cumulative initiating ART
Lost to follow up
Reported dead
Number of patients
Source: ICAP URS, February 2009
Note: Includes sites currently supported by ICAP and reporting.
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

27. Cumulative enrollment in ICAP-supported HIV care and treatment programs by ART status, age, and sex
Total care enrollment (n=519,665)
Total ART enrollment (n=235,746)
Source: ICAP URS, February 2009
Note: Includes sites currently supported by ICAP. Does not include data from MTCT+ sites
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.

28. % patients initiating ART
Proportion of patients ever enrolled in HIV care who initiated ART in ICAP-supported care and treatment programs as of December 2008
% patients initiating ART
Source: ICAP URS, February 2009
Note: Includes sites currently supported by ICAP and reporting.
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 , South Africa , Ethiopia, and Rwanda where the majority are in ART care.
n=33,742
n=37,817
n=43,459
n=57,523
n=9,261
n=519,665
n=1,850
n=65,883
n=67,868
n=39,951
n= 162,311

29. Cumulative enrollment in ICAP-supported HIV care and treatment programs by age and sex as December 2008
n=283,919
n=235,746
n=519,665
% patients
Source: ICAP URS, February 2009
Note: Includes sites currently supported by ICAP. Does not include data from MTCT+ sites
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.

30. Cumulative HIV care enrollment of women and children in ICAP-supported HIV care and treatment programs as of December 2008
% patients in HIV care
Source: ICAP URS, February 2009
Note: Includes sites currently supported by ICAP and reporting.
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, the proportion of children is driven by the Pediatric Centers of Excellence. The proportion in regular sites are lower.
n=519,665
n=33,742
n=43,459
n=37,817
n=57,523
n=39,951
n=67,868
n=9,261
n=1,850
n=65,883
n=162,311

31. Cumulative ART enrollment by women and children in ICAP-supported HIV care and treatment programs as of December 2008
% patients on ART
Source: ICAP URS, February 2009
Note: Includes sites currently supported by ICAP. Does not include data from MTCT+ sites
Take home message:
The patient population varies across ICAP-supported countries, reflecting differences in the epidemic as well as differences in entry points. Overall, 9% of our patient population are children under 15. Note that a smaller proportion of children (9% v.s. 10%) are on ART, likely reflecting difficulties making diagnosis of HIV infection in children.
n=235,746
n16,361
n=19,543
n=18,328
n=25,575
n=21,753
37,916
n=3,782
n=38,548
n=1,146
n=52,794

32. % pediatric patients in HIV care
Cumulative pediatric HIV care enrollment in ICAP supported HIV care and treatment programs as of December 2008
n=53,897
n=4,725
n=9,162
n=14,212
N=4,968
n=1,106
n=5,946
n=2,800
n=6,673
n=4,235
n=70
% pediatric patients in HIV care
Source: ICAP URS, February 2009
Note: Includes sites currently supported by ICAP and reporting.
Take home message:
Large majority of pediatric patients receiving HIV care were under 5 year of age (62%). In Nigeria and Zambia, the majority of pediatric patients were under 1 while in most other countries, the bulk of children in care were 5-14.

33. % pediatric patients on ART
Cumulative pediatric ART enrollment in ICAP-supported HIV care and treatment programs
as of December 2008
n=22,103
n=1,182
n=3,717
n=4,589
n=627
n=2,968
n=2,551
n=1,261
n=2,872
n=2,297
n=39
% pediatric patients on ART
Source: ICAP URS, February 2009
Note: Includes sites currently supported by ICAP and reporting.
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 (22% v.s. 40% from previous slide).

34. % patients eligible for ART
ART initiation among patients eligible for ART in ICAP-supported HIV care and treatment programs, October-December 2008 (n=22,151)
n=22,151
n=3,455
n=2,198
n=4,885
n=3,233
n=1,012
n=382
n=1,296
n=3,098
n=2,332
n=260
% patients eligible for ART
Source: ICAP URS, February 2009
Note: Includes sites currently supported by ICAP and reporting.
Take home message:
Overall 27% of those eligible for ART care were not started on ART. Kenya and Tanzania have the highest number of eligible patients not initiating ART closely followed by Mozambique.
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.

35. ART regimens distributed to adults in ICAP-supported HIV care and treatment programs,
October-December 2008
Overall (Adults)
n=133,957*
Overall (Children)
n=16,358**
1st line regimen
130,672
14,164
d4T-3TC-NVP
72,802 (54%)
5,736 (35%)
d4T-3TC-EFV
31,816 (24%)
2,598 (16%)
ZDV-3TC-NVP
17,812 (13%)
4,042 (25%)
ZDV-3TC-EFV
6,427 (5%)
957 (6%)
Other
1,815 (1%)
831 (5%)
2nd line regimen
663 (0.5%)
97 (0.6%)
Unknown regimen
2,622 (2%)
2,097 (13%)
Source: ICAP URS, February 2009
Note1: Includes sites currently supported by ICAP and reporting.
Note2: The numbers represent patients on ART at the end of the quarter, 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 (.5% of adults and .6% of children) are on 2nd line regimens. Overwhelming majority of patients are on just four first line regimens, reflecting the public health approach to ART scale-up.
151,951 were reported on currently on ART. 17,994 patients did not have regimen information. Over 80% of Nigeria’s regimen
information was missing.
** 17,802 were reported on currently on ART. 16,358 patients did not have regimen information. Over 80% of Nigeria’s regimen
information was missing.

36. ART regimens distributed to adults in ICAP-supported HIV care and treatment programs,
October-December 2008
Cote d'Ivoire
Ethiopia
Kenya
Lesotho
Mozam-bique
Nigeria
Rwanda
South Africa
Tanzania
Zambia
n=1046
n=22494
n=12837
n=8551
n=35223
n=3127
n=13415
n=25195
n=12005
n=64
1st line regimen
1001
22337
12668
8541
32922
3119
13264
24796
11968 56
(95.7%)
(99.3%)
(98.7%)
(99.9%)
(93.5%)
(99.7%)
(98.9%)
(98.4%)
(87.5%)
2nd line regimen 40 85 54 10
102 8 99
243 22
(3.8%)
(0.4%)
(0.1%)
(0.3%)
(0.7%)
(1%)
(0.2%)
(0%)
Unknown 5 72
115  0
2199 52
156 15
(0.5%)
(0.9%)
(0.0%)
(6.2%)
(0.6%)
(12.5%)
Source: ICAP URS, February 2009
Note 1: Includes sites currently supported by ICAP and reporting.
Note2: The numbers represent patients on ART at the end of the quarter, not cumulatively 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 are on 2nd line regimens. Regimen information appears to be poorly recorded in Cote d’Ivoire, Kenya, and Nigeria. Also, the overwhelming majority of patients are on just a few (3) first line regimens, reflecting the public health approach to ART scale-up.

37. ART regimens distributed to children in ICAP-supported HIV care and treatment programs, October-December 2008
Cote d'Ivoire
Ethiopia
Kenya
Lesotho
Mozambique
Nigeria
Rwanda
South Africa*
Tanzania
Zambia
n=36
n=1932
n=1755
n=312
n=3492
n=159
n=1749
n=2595
n=905
n=3423
1st line regimen 36
1920
1647
312
2144
158
1734
2515
905
2793
(100%)
(99%)
(94%)
(61%)
(97%)
(82%)
2nd line regimen 8 14 1 10 56
(0.0%)
(0.4%)
(0.8%)
(0.2%)
(0.63%)
(0.6%)
(2.2%)
Unknown 4 94
1340 5 24
630
(5.4%)
(38.4%)
(0%)
(0.3%)
(0.9%)
(18.4%)
Source: ICAP URS, February 2009
Note1: Includes sites currently supported by ICAP and reporting.
Note2: The numbers represent patients on ART at the end of the quarter not cumulatively on ART.
Take home message:
The large majority of pediatric patients enrolled in ICAP-supported HIV care and treatment programs are on 1st line regimens. Very few are on 2nd line regimen. The overwhelming majority of patients are on just a few first line regimens, reflecting the public health approach to ART scale-up.
* In South Africa, D4T-3TC-LPV/r , ZDV-ddl-LPV/r , and ABC-ddl-LPV/r are prescribed as a first-line regimen for pediatric patients.

38. % patients with CD4 count
Proportion of patients with CD4 count at baseline, 6, and 12 months after ART initiation, as of December 2008
% patients with CD4 count
Source: ICAP URS, February 2009
Note1: Baseline data is 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: 244
Kenya:  113
Lesotho:  34
Mozambique:  196
Nigeria:  36
Rwanda:  240
South Africa:  148
Tanzania:  84
TOTAL:  1,095
Take home message:
There is substantial variability between countries. The baseline CD4 completeness appears to be good for South Africa, Rwanda, Ethiopia, and Lesotho but it is lower in Kenya, Mozambique, Nigeria, and particularly Tanzania. Follow-up CD4 completeness is concerning. Overall, 44% and 43% of the patients in the cohorts had 6 months and 12 months follow up evaluations, respectively.

39. Average median CD4 count at baseline and 6 and 12 months after ART initiation, as of December 2008
Source: ICAP URS, February 2009
Note1: Weighted average of median CD4 counts at baseline and 6/12 months follow up are presented where medians are weighted by the number of patients in the cohort who had a CD4 evaluation. The baseline median cd4 count is an average of 6 and 12 month baseline measurements.
Note2: Data not available for Swaziland and Zambia
Note 3:
Number of matched cohorts by country:
Ethiopia: 244
Kenya:  113
Lesotho:  34
Mozambique:  196
Nigeria:  36
Rwanda:  240
South Africa:  148
Tanzania:  84
TOTAL:  1,095
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 24% (Tanzania) 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.

40. Change in median CD4 count
Change in Median CD4 count (cells/µL) at 6 and12 months of ART, as of December 2008
Change in median CD4 count
Source: ICAP URS, February 2009
Note: Data not available for Swaziland and Zambia.
Note 2: Weighted average of median CD4 counts at baseline and 6/12 months follow up are presented where medians are weighted by the number of patients in the cohort who had a CD4 evaluation. The baseline median cd4 count is an average of 6 and 12 month baseline measurements.
Note 3:
Number of matched cohorts by country:
Ethiopia: 244
Kenya:  113
Lesotho:  34
Mozambique:  196
Nigeria:  36
Rwanda:  240
South Africa:  148
Tanzania:  84
TOTAL:  1,095
Take home message:
CD4 change between baseline and at 6 months vary across countries from 148 in Tanzania to 112 in Rwanda. CD4 change between baseline and at 12 months varies more from 209 in Tanzania to 158 in Rwanda.

41. *Includes patients who transferred out while on ART.
Status of ART patients at ICAP-supported HIV care and treatment programs as of December 2008 (n= 235,746)
Lost to
follow-up
62%
92.8 per 1,000 person-years
50.2 per 1,000 person-years
Source: ICAP URS, February 2009
Note1: Includes sites currently supported by ICAP and reporting.
Take home message:
Among those discontinued ART (19%), the majority (62%) had not had contact with the clinic for by at least 90 days (Lost to follow up), 33% had been reported dead and 5% stopped treatment stopped ART but continued in care.
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 33%
7.2 per 1,000 person-years
Stopped ART 5%
*Includes patients who transferred out while on ART.

42. Reasons for ART discontinuation in ICAP-supported HIV care and treatment programs as of December 2008
% patients
Source: ICAP URS, November 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 81% and 76%.
n=5,906
n=4,812
n=2,028
n=1,749
n=172
n=11,299
n=7,341
n=7,566
n=2,926

43. PMTCT services 43

44. Pregnant women counseled and tested in ICAP-supported PMTCT programs, April 2007 – December 2008
Source: ICAP URS, February 2009
Note: 321 sites in Cote d’Ivoire (26), Ethiopia (54), Lesotho (23), Mozambique (43), Nigeria (133), Rwanda (34), South Africa (8)
ART prophylaxis includes women eligible for and initiating ART.
Take home message:
Overall, ICAP has counseled and tested over 400,000 pregnant women between April 2007 and December ,954 were found HIV positive and 18,086 were subsequently given ART prophylaxis. 44

45. Pregnant women counseled and tested in ICAP-supported PMTCT programs April 2007 – December 2008
Source: ICAP URS, February 2009
Note: % counseled and % tested are calculated using 1st ANC visit as the denominator.
%ART prophylaxis is the proportion of HIV infected pregnant women receiving any ART prophylaxis including therapeutic ART
Take home message:
Overall, ICAP has counseled and tested nearly 400,000 pregnant women from April 2007 through December ICAP counseled and tested most pregnant women coming for their 1st ANC visit at an ICAP supported pmtct site (95%). ART prophylaxis has been given to 71% of those who were HIV positive. However as you will see below, the trend is positive. 45

46. Pregnant women counseled and tested in ICAP-supported PMTCT programs over time
Source: ICAP URS, February 2009
Take home message:
Overall, number of women counseled and tested increasing dramatically as we take on a large number of new sites. 46

47. Pregnant women counseled and tested in ICAP-supported PMTCT programs over time
Source: ICAP URS, February 2009
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 (6%-12%). But proportion of positive women who receive ART prophylaxis has increased from 63% to 92% April-June 2007 to July-September 2008 though it decreased in the most recent quarter.
Note: Jan-Mar 08 quarter, addition of Cote d’Ivoire with low coverage and Nigeria struggled with prophylaxis coverage that quarter brought down the average.
First ANC 47

48. Pregnant women counseled and tested in ICAP-supported PMTCT programs by country, April December 2008
Source: ICAP URS, February 2009
Most women who come for their first ANC visit get counseled about HIV and tested. More than half of infected women received ART prophylaxis cumulatively since April 2007 in all countries. Problems in accurately recording when prophylaxis given lead to underestimates of prophylaxis coverage in ANC.
First ANC
n=32,575
n=3,010
n=103,320
n=160,406
n=5,810
n=64,951
n=22,142 48

49. Type of ART prophylaxis at ICAP-supported PMTCT programs, April 2007 - December 2008
n=198
n=630
n=1,101
n=8,848
n=4,849
n=1,711
n=749
n=18,086
Source: ICAP URS, February 2009
Note: Multi-drug regimens include AZT/sd-NVP, AZT/3TC tail postpartum, HAART at 34 weeks.
Take home message:
Overall, countries are moving toward dispensing more complex regimens than Sd-NVP. Indeed, in all countries except in Cote diIvoire the majority of women either receive Sd-NVP and AZT, HAART at 34 weeks or ART. 49

50. Type of ART prophylaxis at ICAP-supported PMTCT programs over time
n = 1,216
n=1,932
n = 2,247
n=2,536
n=2,931
n=3,966
n=3,258
Source: ICAP URS, February 2009
Note: Multi-drug regimens include AZT/sd-NVP, AZT/3TC tail postpartum, HAART at 34 weeks.
Take home message:
Overall, countries are moving toward dispensing more complex regimens than Sd-NVP.

51. TB Screening in HIV Care Settings

52. The Data: TB Screening in HIV Care Settings
As of December 2008…
Country
Sites supported
Sites reporting
Cote d’Ivoire 23 21
Ethiopia 51 *
Kenya 73
Mozambique 35 32
Nigeria 57
Rwanda 44
South Africa 37 24
Tanzania 77 74
397
325 (82%)
Ethiopia reported TB treatment data only (42 sites)

53. Proportion of new HIV patients screened for TB at enrollment in ICAP-supported HIV care and treatment programs,
October-December 2008
% patients
Source: ICAP URS, February 2009
Note: Overall 325 sites contributed data. Country breakdown is as follows: Cote d’Ivoire=21 sites, Mozambique=32 sites, South Africa=24 sites, Rwanda=44 sites, Nigeria=57 sites, Kenya=73 sites, Tanzania=74 sites.
Note: Note the different sizes of the programs.
Nigeria and Mozambique are large programs having over 40,000 new HIV patients cumulatively since January 2007.
Tanzania, Rwanda and Kenya are mid-size programs having between 20,000 and 40,000 new HIV patients cumulatively since January 2007.
Cote d’Ivoire and South Africa appear to be smaller programs. This is due primarily to the fact that both countries began reporting TB screening numbers late. Cote d’Ivoire began in April-June 2008 quarter; South Africa in July-September 2008 quarter.
Take home message:
In Tanzania the target of >90% is nearly met while other countries lag behind. However, overtime most countries are making substantial improvements. (see next slide)
n=29,081
n=3,538
n=2,235
n=770
n=7,197
n=5,187
n=8,023
New HIV patients
n=2,131
Tanzania close to SOC target of > 90%
In other countries, many patients are not screened at enrollment

54. Proportion of new HIV patients screened for TB at enrollment in ICAP-supported HIV care and treatment programs over time
% patients
Source: ICAP URS, February 2009
Note: Cote d’Ivoire began in April-June 2008 quarter; South Africa in July-September 2008 quarter.
Take home message:
Overall, there has been a slow but steady increase in the number of newly enrolled HIV patients screened for TB at enrollment (48% 67%). The number of sites reporting TB screening information has tripled (122 367). We remain, however, well below our target of >90%. Increase in the number of sites have not affected the increase.
New HIV patients
n=8,685
n=14,824
n=18,886
n=19,104
n=23,991
n=24,705
n=32,760
n=29,081
Proportion screened for TB has increased over time,
but still falls short of SOC target of > 90%

55. Proportion of new HIV patients screened for TB at enrollment in ICAP-supported care and treatment programs over time, by country
% patients
Source: ICAP URS, February 2009
Take home message:
Examining the trend by country, both Rwanda and Tanzania started out with high proportion of patients being screened (75%, 69%) and have steadily increased. Since December 07 the proportion has remained above 80% reaching close to 100% in the October-December 2008 quarter.

56. Proportion of new HIV patients screened for TB at enrollment in ICAP-supported care and treatment programs over time, by country
% patients
Source: ICAP URS, February 2009
Take home message:
Kenya, Mozambique started out low (40%, 26%) and have steadily increased.

57. Proportion of new HIV patients screened for TB at enrollment in ICAP-supported care and treatment programs over time, by country
% patients
Source: ICAP URS, February 2009
Note: Cote d’Ivoire began in April-June 2008 quarter; South Africa in July-September 2008 quarter.
Take home message:
Nigeria’s trend appears to be still uncertain. Cote d’Ivoire has improved dramatically in a short span of time.

58. Proportion of HIV patients screened for TB who screened positive at ICAP-supported care and treatment programs, October-December 2008
% patients
Source: ICAP URS, February 2009
Note: Cote d’Ivoire began in April-June 2008 quarter; South Africa in July-September 2008 quarter.
Note: Overall 367 sites contributed data. Country breakdown is as follows: Cote d’Ivoire=21 sites, Mozambique=32 sites, South Africa=24 sites, Rwanda=44 sites, Nigeria=57 sites, Kenya=73 sites, Tanzania=74 sites.
Take home message: Cote ’d Ivoire, Mozambique and South Africa have relatively higher proportion of patients being screened positive. This may be due in part by bias in screening or recording of results. The screening questionnaire may be only administered to those who are symptomatic rather than being administered to all new HIV patients. Alternatively, results of the screening could be recorded only when the tool is administered to a symptomatic patient.
Screened patients
n=19,610
n=4,614
n=528
n=1,458
n=3,855
n=3,619
n=3,441
n=2,095
Proportion screened positive varies substantially across countries
Results from Moz, CDI, SA may be inflated due to selection bias

59. Screened positive patients
Proportion of new HIV patients with a positive TB screen who initiated TB treatment at ICAP-supported care and treatment programs, October-December 2008
% patients
Source: ICAP URS, February 2009
Note: Cote d’Ivoire began in April-June 2008 quarter; South Africa in July-September 2008 quarter.
Note: Overall 367 sites contributed data. Country breakdown is as follows: Cote d’Ivoire=21 sites, Mozambique=32 sites, South Africa=24 sites,
Rwanda=44 sites, Nigeria=57 sites, Kenya=73 sites, Tanzania=74 sites.
Take home message:
Overall, only 20% of screen positive patients were subsequently diagnosed/treated. Are the screening tools non-specific? In Nigeria, 60% of screened positive patients are subsequently diagnosed and initiating TB treatment. Why is this so high? na
Screened positive patients
n=4,596
n=510
n=596
n=637
n=2,371
n=259
Proportion diagnosed/treated (among those with positive screen)
varies substantially across countries
This may be due to biased screening

60. Proportion of new HIV patients who initiated TB treatment at ICAP-supported care and treatment programs, October-December 2008
% patients
Source: ICAP URS, February 2009
Note: Cote d’Ivoire began in April-June 2008 quarter; South Africa in July-September 2008 quarter.
Note: Overall 367 sites contributed data. Country breakdown is as follows: Cote d’Ivoire=21 sites, Mozambique=32 sites, South Africa=24 sites,
Rwanda=44 sites, Nigeria=57 sites, Kenya=73 sites, Tanzania=74 sites.
Take home message:
Overall, only 6% of all new HIV patients were diagnosed/treated for TB. Are we underdiagnosing?
n=29,081
n=3,538
n=2,235
n=770
n=7,197
n=5,187
n=8,023
New HIV patients
n=2,131
Proportion diagnosed/treated (among all new patients) is very low
in all countries compared to the literature (25%-50%)

61. HIV Testing in TB Clinics

62. The Data: HIV testing in TB clinics
As of December 2008…
Country
Sites supported
Sites reporting
Cote d’Ivoire 7
Ethiopia 51 49
Kenya 73 72
Mozambique 32
Nigeria 71 57
Rwanda 29 28
South Africa 2
Tanzania NA
265
247 (93%)

63. Proportion of new patients with an unknown HIV status at ICAP-supported TB clinics who were HIV tested, Oct-December 2008
Tested at TB clinic
Tested at any clinic
% patients
Source: ICAP URS, February 2009
Note: Overall 247 sites contributed data. (Rw 29, Ng 57, Kn 72, CDI 7, Eth 49, SA 2, Mz 32 sites).
Note: Rwanda began reporting information from the TB clinic October Cote d’Ivoire January 2008 and Mozambique April 2007.
Note: Nigeria had >100% HIV testing among new TB patients. Queries are being sent to these countries to verify these numbers.
In Nigeria, Ethiopia, and South Africa, the bar represents the proportion of new TB patients with an unknown HIV status who were HIV tested at the TB clinic upon enrollment. Note that numbers from South Africa are from TB hospitals.
In Mozambique, Rwanda, CDI, Tanzania, and Kenya, the bar represents those new TB patients who were HIV tested at any clinic.
Note: Ethiopia represents nearly 60% of all ICAP supported TB patients seen at ICAP supported TB clinics.
Take home message:
In South Africa, Mozambique and Cote d’Ivoire, a significant number of new enrollees in TB treatment programs were not HIV tested at enrollment.
New TB patients
n=11,295
n=952
N=6,054
n=551
n=296
n=1,971
n=240
n=1,231
Proportion of new TB patients who are HIV tested is relatively high

64. Proportion of new patients with unknown HIV status at ICAP-supported TB clinics tested for HIV over time
% patients
Source: ICAP URS, February 2009
Note: Overall 247 sites contributed data. (Rw 29, Ng 57, Kn 72, CDI 7, Eth 49, SA 2, Mz 32 sites).
Note: Rwanda began reporting information from the TB clinic October Cote d’Ivoire January 2008 and Mozambique April 2007.
Take home message:
Overall, there has been a slow but steady increase in the number of newly enrolled TB patients tested for HIV at enrollment (78% 90%). As ICAP, we appear to be meeting our SOC target of HIV testing >90% of TB patients with an unknown HIV status at enrollment since July-September 08 quarter, but important differences remain across countries as shown in the previous slide. Number of sites have grown rapidly from sites.
New HIV patients
n=7,441
n=6,955
n=7,481
n=7,271
n=10,027
n=8,700
n=10,781
n=11,295
Proportion new TB patients HIV tested has increased over time
For the past three quarters, we have reached the SOC target >90%.

65. HIV tested at any clinic
Proportion of HIV tested TB patients at ICAP-supported TB treatment programs who tested positive, October-December 2008
HIV tested at TB clinic
HIV tested at any clinic
% patients
Source: ICAP URS, February 2009
Note: Overall 247 sites contributed data. (Rw 29, Ng 57, Kn 72, CDI 7, Eth 49, SA 2, Mz 32 sites).
Note: Rwanda began reporting information from the TB clinic October Cote d’Ivoire January 2008 and Mozambique April 2007.
Note: Ethiopia represents about 60% of all ICAP supported TB patients HIV tested at ICAP supported TB clinics.
Take home message:
Proportion of new TB patients tested HIV positive is relatively similar across countries, except in Cote d’Ivoire and Ethiopia. It is important to note that this indicator does not necessarily measure the HIV prevalence among TB patients in Ethiopia, Sough Africa and Nigeria because the bar excludes known positives.
HIV tested TB patients
N=10,185
N=245
n=937
n=5,888
n=882
n=1,752
n=292
n=189
Proportion new TB patients tested HIV positive is relatively similar
across countries except in Cote d’Ivoire and Ethiopia.

66. Proportion of HIV(+) TB patients enrolling in HIV care at ICAP-supported TB treatment programs, October-December 2008
% patients
Source: ICAP URS, February 2009
Note: Overall 247 sites contributed data. (Rw 29, Ng 57, Kn 72, CDI 7, Eth 49, SA 2, Mz 32 sites).
Note: Rwanda began reporting information from the TB clinic October Cote d’Ivoire January 2008 and Mozambique April 2007.
Take home message:
In South Africa, Mozambique and Ethiopia, a significant number of HIV positive TB patients enrolled in HIV care and treatment programs. In South Africa and in Rwanda, because HIV care and treatment services are available at the TB hospitals, the proportion is high.
HIV positive patients
n=2,027
n=112
n=403
n=360
n=384
n=660
n=31
In sites with HIV care and treatment on-site (SA, Rwanda),
enrollment in HIV care is universal.