1. Data reported through June 2009
ICAP MASTER SLIDE DECK
Data reported through June 2009
Notes:
Swaziland has not reported for the April-June 2009 quarter, so the results from January-March 2009 were carried over
PFACTS Slides are based off of PFACTS Round 3 data

2. Number of ICAP-supported sites by activity, June 2009 (n=935)
Number of sites
Source: ICAP Site Census, June 2009
Take home message:
As of January 2009, ICAP supported 935 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.
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.

3. Number of ICAP-supported sites by country, June 2009 (n=935)
Number of sites
Source: ICAP Site Census, June 2009
Take home message:
ICAP supports sites in 11 different countries. Tanzania further expended the number of sites from 312 sites, mainly due to the expansion of PMTCT services.

4. Care and treatment indicators

5. 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

6. Location and type of ICAP-supported HIV care and treatment sites (n=341, June 2008)
Source: PFaCTS, June 2008
Note: There were 362 in April-June 2008; 348 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 41, Kenya 71, Lesotho 23, Mozambique 39, Nigeria 27, Rwanda 43, South Africa 37, Swaziland 6, Tanzania 45 sites, Thailand 1, Uganda 2 sites, Zambia 1 site.
Missing: 7 sites missing primary / secondary / tertiary breakdown (approx .006%)
Take home message:
The majority (56%; 192 out of 341 of the ICAP-supported care and treatment sites are located in urban areas. In urban areas, the majority (65%) 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.

7. Proportion of ICAP-supported HIV care and treatment sites offering HIV-related services on site (n=341, June 2008)
% sites with services
Source: PFaCTS, July2008
Note: n=341
Take home message:
Large majority (74-92%) of ICAP-supported care and treatment sites offer additional HIV-related services on-site.

8. Proportion of sites offering HIV-related services on-site, by number of services (n=341, June 2008)
Source: PFaCTS, June 2008
Note: Services include: VCT, TB treatment, PMTCT, Labor and delivery, and ART pharmacy.
Take home message:
49% of ICAP-supported care and treatment sites provide all 5 HIV-related services on site. This is not surprising as many of ICAP-supported sites are secondary and tertiary health facilities in urban areas.

9. Proportion of ICAP-supported sites offering ≥4 HIV-related services on site (n=338, June 2008)
Average =76%
% 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.

10. Proportion of ICAP-supported sites offering on-site patient support services, by type of service (n=323, June 2008)
% 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

11. Proportion of HIV care and treatment sites offering on-site patient support services, by number of services offered (n=323, June 2008)
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 (57%) only offer 1-2 patient support services, which are most commonly on-site adherence support and outreach services

12. % of sites with ≥ 4 services
Proportion of ICAP-supported HIV care and treatment sites with ≥4 on-site patient support services (n=241)
Average =45%
% of sites with ≥ 4 services
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.

13. High proportion of ICAP-supported sites have access to key HIV-related laboratory assays
Source: PFaCTS, June 2008
Note: n=342
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-two percent (78%+4%) of the sites have access either on or off site ID/PCR service, and only 38% (6%+32%) of the sites have access either on or off site HIV-RNA service.

14. Proportion of ICAP-supported HIV care and treatment sites with access to laboratory assays by number of assays (n=336, June 2008)
Source: PFaCTS, June 2008
Note1: Laboratory assays include: CD4, CD4 percent, HIV-RNA, early infant diagnosis, LFT, and blood chemistry.
Take home message:
The majority of ICAP-supported care and treatment sites have access to a comprehensive array of HIV-related laboratory test services.

15. Proportion of ICAP-supported sites with access to key HIV-related lab assays (n=342, June 2008)
Average =98%
% 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.
Key laboratory assays include: CD4, CD4 percent, HIV-RNA, LFT, and blood chemistry. PCR laboratory tests are excluded.

16. Proportion of ICAP-supported sites with access to PCR laboratory assays (n=325, June 2008)
Average =92%
% sites
Source: PFaCTS, June 2008
Take home message:
Across countries there is a wide range of variability in availability of PCR.

17. Mean number of providers
Mean number of full-time health care providers at HIV care and treatment sites (n=348, June 2008)
Mean number of providers
Source: PFaCTS, June 2008
Take home message:
There is wide variability in number of providers in ICAP supported countries. Overall, an average of 4 health care providers provided services to patients at ICAP-supported facilities. 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.

18. Mean number of outreach workers
Mean number of outreach workers at ICAP-supported HIV care and treatment sites with outreach programs (n=183, June 2008)
Mean number of outreach workers
Source: P-FaCTS, June 2008
Note: Sites with outreach programs only.
Take home message:
There is wide variability in number of outreach workers in ICAP supported countries. Overall, an average of 1 outreach worker provided services to patients at ICAP-supported facilities.

19. Trend in proportion of ICAP-supported sites offering on-site patient support services (n=175, June 2008)
% of sites
Source: PFaCTS, June 2008
N = 175 sites
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 each round are included).
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.
ART adherence support: Verbal patient education provided by trained personnel at least every 3 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 19

20. Prevention services are offered at most ICAP-supported sites (n=71, June 2008)
Source: PFaCTS, June 2008
Note: Only sites that answered for all rounds of data collection were included in the analysis.
Note: n=71
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. 20

21. Care and treatment
quarterly indicators

22. HIV care and treatment services, as of June 2009

23. New enrollment in care and treatment programs
# of new patients
Source: ICAP URS June 2009

24. Cumulative enrollment in ICAP-supported HIV care and treatment programs (currently reporting)
482 sites
Swaziland
Cote d’Ivoire
Nigeria,
Zambia
Number of facilities
Number of patients
671,749 ever enrolled in care
Lesotho, Rwanda,
S. Africa,
Tanzania
Ethiopia
Mozambique
Source: ICAP URS, June 2009
Note1: Includes sites currently supported by ICAP and reporting.
Note2: The country boxes depict when the country started contributing data, not necessarily when the program began
Take home message:
ICAP is expanding rapidly adding country programs every year. To date, among the currently supported sites, ICAP supports 671,749 patients with HIV care and 327,092 patients with ART care.
327,092 ever initiated ART

25. Cumulative pediatric enrollment in ICAP-supported HIV care and treatment programs (currently reporting)
482 sites
Swaziland
Cote d’Ivoire
Nigeria,
Zambia
Number of facilities
Number of patients
69,575 ever enrolled in care
Lesotho, Rwanda,
S. Africa,
Tanzania
Ethiopia
Mozambique
Source: ICAP URS, March 2009
Note1: Includes sites currently supported by ICAP and reporting.
Note2: Swaziland is included as of March 2009.
Note3: Zambia was unable to report Jan-Mar 08 quarter. Oct-Dec 07 numbers were carried over.
Note 4: Swaziland was unable to report Apr-June; Numbers from Jan-Mar 09 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 date63,364 pediatric patients were in care (10% of all patients) and 28,031 of them were on ART (9% of all patients).
30,859 ever initiated ART

26. Cumulative enrollment in HIV care in ICAP-supported HIV care and treatment programs by country (n= 671,749)
Swaziland
Cote d’Ivoire
Zambia
Nigeria
Lesotho
Tanzania
Number of patients
Kenya
Rwanda
Ethiopia
South Africa
Source: ICAP URS, June 2009
Note: Includes sites currently supported by ICAP and reporting.
Note2: Zambia was unable to report Jan-Mar 08 quarter. Oct-Dec 07 numbers were carried over.
Note 3: Swaziland was unable to report Apr-June; Numbers from Jan-Mar 09 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 11 country programs supported by ICAP.
Mozambique - green; South Africa – turquoise; Ethiopia – grey; Rwanda – blue; Kenya –yellow ; Tanzania – dark grey; Lesotho – light blue; Nigeria – orange; Zambia black; Cote d’Ivoire – yellow; Swazi - grey
Mozambique

27. Cumulative enrollment on ART at ICAP-supported HIV care and treatment programs by country (n=327,092)
Swaziland
Cote d’Ivoire
Nigeria
Zambia
Lesotho
Tanzania
Number of patients
Kenya
Rwanda
Ethiopia
Source: ICAP URS,June 2009
Note: Includes sites currently supported by ICAP and reporting.
Note2: Zambia was unable to report Jan-Mar 08 quarter. Oct-Dec 07 numbers were carried over.
Note 3: Swaziland was unable to report Apr-June; Numbers from Jan-Mar 09 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 11 country programs supported by ICAP.
Mozambique – purple; South Africa – Red; Ethiopia – teal; Rwanda – blue; Kenya – light green; Tanzania – Orange; Lesotho – green; Nigeria – light blue; Zambia – pink ; Cote d’Ivoire – black; Swaziland teal
South Africa
Mozambique

28. Cumulative person-years on ART
Cumulative person-years on ART at ICAP-supported care and treatment programs, as of June 2009
Cumulative person-years on ART
Source: ICAP URS, June 2009
Note : Swaziland was unable to report Apr-June; Numbers from Jan-Mar 09 were carried over
Definitions:
Cumulative person years on ART is calculated as the cumulative number of patients on ART by time they have been on ART. Those who are known to have died, transferred or lost to follow up stop contributing time when their new status is reported.
Take home message:
ICAP supported care and treatment programs have accumulated over 382,516 cumulative person-years of experience on ART at the end of the April-June 2008 reporting quarter.

29. Cumulative initiating ART ART patients retained in care
Cumulative and current enrollment in ART care at ICAP-supported HIV care and treatment programs as of June 2009 (n= 327,092)
Cumulative initiating ART
Lost to follow up
Number of patients
Reported dead
Source: ICAP URS, June 2009
Note: Swaziland was unable to report Apr-June; Numbers from Jan-Mar 09 were carried over
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

30. Cumulative enrollment in ICAP-supported HIV care and treatment programs by ART status, age, and sex, as of June 2009
Total care enrollment (n=671,749)
Total ART enrollment (n=327,092)
Children <15
Children <15
Men 15+
Men 15+
Women 15+
Women 15+
Source: ICAP URS, June 2009
Note: Swaziland was unable to report Apr-June; Numbers from Jan-Mar 09 were carried over
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. Proportion of children in HIV care and ART remain low across quarters.

31. % patients initiating ART
Proportion of all enrolled patients who initiated ART in ICAP-supported treatment programs as of June 2009
% patients initiating ART
Source: ICAP URS, June 2009
Note: Includes sites currently supported by ICAP and reporting.
Note 2: For Swaziland, the denominator includes a small fraction of pre-ART patients
Note 3: Swaziland was unable to report Apr-June; Numbers from Jan-Mar 09 were carried over
Take home message:
Overall, 49% 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 Swaziland, Cote d’Ivoire , South Africa , Ethiopia, and Rwanda where the majority are in ART care.
n=10,526
n=671,749
n= 44,557
n=41,237
n=58,766
n=86,116
n=34,517
n=77,362
n=46,058
n=79,256
n=3,589
n=188,765

32. Cumulative enrollment in HIV care and treatment programs by age and sex, as of June 2009
% patients
Source: ICAP URS, June 2009
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.

33. Children represent 10% of those in care (cumulative as of June 2009)
% patients in HIV care
Source: ICAP URS, June 2009
Note: Includes sites currently supported by ICAP and reporting.
Note: Swaziland was unable to report Apr-June; Numbers from Jan-Mar 09 were carried over
Take home message:
The patient population in HIV care 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 large Pediatric Centers of Excellence. The proportion in regular sites are lower.
n=671,749
n=86,116
n=3,589
n=41,237
n=79,256
n=46,058
n=58,766
n=188,765
n= 44,557
n=35,517
n=77,362
n=10,526

34. Children represent 9% of patients initiating ART (cumulative as of June 2009)
% patients on ART
Source: ICAP URS, June 2009
Note: Includes sites currently supported by ICAP. Does not include data from MTCT+ sites
Note: Swaziland was unable to report Apr-June; Numbers from Jan-Mar 09 were carried over
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 (10% v.s. 9.0%) are on ART, likely reflecting difficulties making diagnosis of HIV infection in children.
n=327,092
n=21,192
n=26,999
n=37,054
n=4,205
n=2,066
n=46,309
n=22,679
n=35,174
n= 24,405
n=43,823
n=63,186

35. Cumulative pediatric HIV care enrollment, as of June 2009
% pediatric patients in HIV care
Source: ICAP URS, June 2009
Note: Swaziland was unable to report Apr-June; Numbers from Jan-Mar 09 were carried over
Take home message:
Large majority of pediatric patients receiving HIV care were under 5 years of age (62%). In Nigeria and Zambia, the majority of pediatric patients were under 1.

36. Cumulative pediatric ART enrollment, as of June 2009
% pediatric patients on ART
Source: ICAP URS, June 2009
Note: Includes sites currently supported by ICAP and reporting.
Note: Swaziland was unable to report Apr-June; Numbers from Jan-Mar 09 were carried over
Take home message:
There is large variability for proportion of <1 year enrolled in ART 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 HIV care (23% v.s. 39% from previous slide).

37. % patients eligible for ART
ART initiation among patients eligible for ART in ICAP-supported programs, April-June 2009
n=1,433
n=1,156
n=5,644
n=2,002
n=425
n=2,768
n=3,846
n=2,705
n=160
n=26,352
n=2,542
n=3,671
% patients eligible for ART
Source: ICAP URS, June 2009
Note: Includes sites currently supported by ICAP and reporting.
Note: Swaziland was unable to report Apr-June; Numbers from Jan-Mar 09 were carried over
Take home message:
Overall 12% of those eligible for ART care were not started on ART. Kenya, Mozambique and Tanzania have the highest number of eligible patients not initiating ART.
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.
Eligible, but not started: 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.

38. ART regimens distributed in ICAP-supported HIV care and treatment programs,
April-June 2009
Source: ICAP URS, June2009
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.
Note 3: Swaziland is excluded
Take home message:
Large majority of patients enrolled in ICAP-supported HIV care and treatment programs are on 1st line regimens. Very few (.37% of adults and 1.2% 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.

39. ART regimens distributed to adults in ICAP-supported HIV care and treatment programs,
April-June 2009
Source: ICAP URS,June 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, Swaziland 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.
* 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.

40. ART regimens distributed to children in ICAP supported HIV care and treatment programs,
April-June 2009
Source: ICAP URS, March 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.

41. % patients with CD4 count
Proportion of patients with CD4 count at baseline, 6, and 12 months after ART initiation
% patients with CD4 count
Source: ICAP URS, June 2009
Note1: Baseline data is average of matched 6 and 12 month cohort data at baseline
Note2: Data not available for Swaziland, Cote d’Ivoire and Zambia.
Note 3: Cumulative number of matched cohorts by country:
Ethiopia: 320
Kenya:  204
Lesotho:  57
Mozambique:  265
Nigeria:  64
Rwanda:  310
South Africa:  208
Tanzania:  128
TOTAL:  1556
Take-home Message: Completion of CD4 evaluation at ART initiation and follow-up vary substantially across countries. Completion at follow-up is worryingly low at 44% (6 months) and 43% (12 months)
n=9,921
n=7,420
n=13,420
n=25,854
n=10,683
n=9,557
n=8,497
n=114,694
n=29,342

42. CD4 Cell Count (cells/ul)
Robust and sustained increases in median CD4 count among cohorts of patients initiating ART
CD4 Cell Count (cells/ul)
Source: ICAP URS, June 2009
Note: 114,692/ 327,092 patients (total number of patients on ART)
Note1: Average of median CD4 counts at baseline and 6/12 months follow up are presented. The baseline median cd4 count is an average of 6 and 12 month baseline measurements.
Note2: Data not available for Swaziland, cote d’ivoire and Zambia
Note3: Cumulative number of matched cohorts by country:
Ethiopia: 320
Kenya:  204
Lesotho:  57
Mozambique:  265
Nigeria:  64
Rwanda:  310
South Africa:  208
Tanzania:  128
TOTAL:  1556
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 26% (Tanzania) of patients in the cohort
Definitions:
Baseline CD4 = average of baselines from 6-mo and 12-mo cohorts.
6-Mo CD4 = average of median CD4 at 6-mo.
12-Mo CD4 = average of median CD4 at 12-mo.
n=9,921
n=7,420
13,420
n=25,854
n=10,683
n=9,557
n=8,497
n=114,694
n=29,342

43. Change in median CD4 count (cells/µL)
Change in Median CD4 count at 6 and12 months of ART, as of June 2009
Change in median CD4 count (cells/µL)
Source: ICAP URS, June 2009
Note1: 114,692/ 327,092
Note 2: Average of median CD4 counts at baseline and 6/12 months follow up are presented. The baseline median cd4 count is an average of 6 and 12 month baseline measurements.
Note3: Data not available for Swaziland and Zambia
Note 3: Number of matched cohorts by country:
Ethiopia: 320
Kenya:  204
Lesotho:  57
Mozambique:  265
Nigeria:  64
Rwanda:  310
South Africa:  208
Tanzania:  128
TOTAL:  1556
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 26% (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.

44. *Includes patients who transferred out while on ART.
Status of ART patients at ICAP-supported HIV care and treatment programs as of June 2009
(n= 327,092)
Lost to Follow-up
10.3% per year on ART
5.3% per year on ART
Reported Dead
Source: ICAP URS, June 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 at least 90 days (Lost to follow up), 34% 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
.59% per year on ART
Stopped ART
*Includes patients who transferred out while on ART.

45. % of Discontinuing Patients
Reasons for ART discontinuation in ICAP-supported HIV facilities as of June 2009
n=167
n=3,200
n=6,520
n=3,511
n=9,277
n=13,541
n=9,124
n=8.078
n=5,909
n=573
n=1,941
% of Discontinuing Patients
Source: ICAP URS, June 2009
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 75%

46. PMTCT indicators

47. Pregnant women counseled and tested in ICAP-supported PMTCT programs, cumulative as of June 2009
# of Women
Source: ICAP URS, June 2009
Note: Tanzania is excluded from PMTCT analysis
Take home message:
Overall, ICAP has counseled and tested over 590,000 pregnant women between April 2007 and June ,417 were found HIV positive (or knew they were already HIV+) and 28,985 were subsequently given ART prophylaxis.

48. Pregnant women counseled and tested in ICAP-supported PMTCT programs, cumulative
as of June 2009
% Women
Source: ICAP URS, March 2009
Note: % counseled and % tested are calculated using 1st ANC visit as the denominator.
%HIV positive includes pregnant women who already knew they were HIV positive
%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 over 420,000 pregnant women from April 2007 through March 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 65% of those who were HIV positive.

49. Pregnant women counseled and tested and prophylaxed in PMTCT programs over time
# of Women
Source: ICAP URS, March 2009
Note: HIV positive includes pregnant women who already knew they were HIV positive

50. Pregnant women counseled and tested in ICAP-supported PMTCT programs over time
Source: ICAP URS, March 2009
Note1: % counseled and % tested are both using 1st ANC visit as the denominator.
Note2: % HIV positive includes women who knew they were HIV positive
Note3: Jan-Mar 08 quarter, addition of Cote d’Ivoire with low coverage and Nigeria struggled with prophylaxis coverage that quarter brought down the average.
Take home message:
Proportion of women attending first ANC and receiving HIV testing as well as the proportion og HIV positive women receiving prophylaxis has increased and decreased over the quarters. It is assumed that new sites have lower testing and prophylaxis coverage, thereby decreasing the overall percentage.
First ANC
n=60, n=67, n=83, n=83, n=91,663

51. Pregnant women counseled and tested in PMTCT programs, by country as of June 2009
Source: ICAP URS, June 2009
Note: HIV positive includes women who knew they were HIV positive
Take home message:
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 in Rwanda, Mozambique, South Africa and Lesotho. Problems in accurately recording when prophylaxis given lead to underestimates of prophylaxis coverage in ANC.
First ANC
n=51,374
n=216,885
n=9,349
n=86,254
n=168,728
n=44,511
n=14,420

52. Type of ART prophylaxis for HIV-positive women at ICAP-supported PMTCT programs, April-June 2009
Source: ICAP URS, June 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 the majority of women either receive Sd-NVP and AZT, HAART at 34 weeks or ART.

53. Time-shift towards more complex PMTCT regimens at PMTCT programs
% of Women
Source: ICAP URS, june 2009
Note: Multi-drug regimens include AZT/sd-NVP, AZT/3TC tail postpartum, HAART at 34 weeks.
Take home message:
Overtime, countries are moving toward dispensing more complex regimens than Sd-NVP.

54. Indicators for TB Screening in HIV Care Settings

55. TB Screening in HIV Care Settings
Source: ICAP URS and Site Census, June 2009

56. Proportion of new HIV patients screened for TB at enrollment, April-June 2009
90% target
% patients
Source: ICAP URS, June 2009
Note1: Overall 341 sites contributed data. Country breakdown is as follows: Cote d’Ivoire=34 sites, Mozambique=39 sites, South Africa=27 sites, Rwanda=46 sites, Nigeria=30 sites, Kenya=79 sites, Tanzania=86 sites.
Note2: Note the different sizes of the programs indicated in the number of new patients.
Note3: Cote d’Ivoire began in April-June 2008 quarter; South Africa in July-September 2008 quarter.
Take home message:
In Tanzania and Rwanda, the target of >90% is met while other countries lag behind.
n=33,079
n=2,411
n=3,942
n=4,723
n=11,469
n=7,011
n=2,539
New HIV patients
n=984

57. Proportion of new HIV patients screened for TB at enrollment in HIV programs over time
% of patients
Source: ICAP URS, June 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 (53% 68%). The number of sites reporting TB screening information has increased six-fold (62 360). We remain, however, well below our target of >90%. Increase in the number of sites appear to be affecting the increase, especially since July – September 08q.
n=17,700
n=18,713
New HIV patients
n=23,094
n=24,661
n=32,959
n=29,281
n=33,173
n=33,079

58. 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, June 2009
Take home message:
Examining the trend by country, both Rwanda and Tanzania started out with high proportion of patients being screened (90%, 83%) and have maintained a high proportion over time.

59. 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, June 2009
Take home message:
Mozambique has stayed under 70% over time. There appears to be a slight upward trend for Kenya.

60. 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, June 2009
Note: Cote d’Ivoire began in April-June 2008 quarter; South Africa in July-September 2008 quarter.
Take home message:
Cote d’Ivoire and South Africa have few data points. In both cases the trend is still uncertain.

61. Proportion of all HIV patients screened for TB who screened positive, April-June 2009
Source: ICAP URS, June 2009
Note: Cote d’Ivoire began in April-June 2008 quarter; South Africa in July-September 2008 quarter.
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.
n=22,409
n=1,316
n=6,037
n=704
n=3,769
n=4,493
n=2,331
Patients screened
n=3,759

62. Patients screened positive
Proportion of all new HIV patients with a positive TB screen who initiated TB treatment at an ICAP-supported program, April-June 2009
% patients
Source: ICAP URS,June 2009
Note: Cote d’Ivoire began in April-June 2008 quarter; South Africa in July-September 2008 quarter.
Take home message:
Overall, only 11% of patients who screened positive were subsequently diagnosed/treated. Are the screening tools non-specific?
n=4,293
n=663
n=452
n=650
n=2,082
n=178
Patients screened positive
n=268

63. Proportion of all new HIV patients who initiated TB treatment at ICAP-supported care and treatment programs, April-June 2009
Source: ICAP URS, June 2009
Note1: Cote d’Ivoire began in April-June 2008 quarter; South Africa in July-September 2008 quarter.
Note2: Ethiopia reports diagnosis data, hence it is reflected in this graph.
Take home message:
Overall, only 7% of all new HIV patients were diagnosed/treated for TB. Are we underdiagnosing?
New HIV
patients
n=37,535
n=2,539
n=3,942
n=4,456
n=11,469
n=7,011
n=4,723
n=2,411
n=984

64. Indicators for HIV Testing in TB Patients

65. HIV testing in TB clinics
as of June 2009
Source: ICAP URS and Site Census, June 2009

66. New TB patients w/ unknown HIV status
Proportion of new patients with an unknown HIV status at ICAP-supported TB clinics who were HIV tested, April-June 2009
Tested at TB clinic
Tested at any clinic
% patients
Source: ICAP URS, June 2009
Note: Overall 256 sites contributed data. (Rw 27, Ng 50, Kn 78, CDI 11, Eth 51, SA 2, Mz 37 sites).
Note: Rwanda began reporting information from the TB clinic October Cote d’Ivoire January 2008 and Mozambique April 2007.
Note: 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 w/ unknown HIV status
n=10, n=6, n= n= n= n=1, n=1, n=181

67. TB patients with unknown HIV status
Proportion of new TB patients with unknown HIV status at ICAP-supported TB clinics tested for HIV over time
% patients
Source: ICAP URS, June 2009
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% 95%). 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.
n=7, n=6, n=7,466 n=7, n=9, n=8, n=11,307 n=11,281 n=11,102 n=10,847
TB patients with unknown HIV status

68. New TB patients tested for HIV
Proportion of HIV tested TB patients at ICAP-supported TB treatment programs who tested positive,
April - June 2009
Tested at TB clinic
Tested at any clinic
% patients
Source: ICAP URS, June 2009
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.
New TB patients tested for HIV
n=10, n= n= n=6, n=1, n= n=1, n=149

69. New TB patients testing positive for HIV
Proportion of HIV(+) TB patients enrolling in HIV care at ICAP TB treatment programs, April-June 2009
Tested at TB clinic
Tested at any clinic
% patients
Source: ICAP URS, June 2009
Note: Overall 252 sites contributed data. (Rw 27, Ng 46, Kn 78, CDI 11, Eth 51, SA 2, Mz 37 sites).
Note: Rwanda began reporting information from the TB clinic October Cote d’Ivoire January 2008 and Mozambique April 2007.
Take home message:
In Kenya, a significant number of HIV positive TB patients are not 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.
New TB patients testing positive for HIV
n=1, n= n= n= n= n= n= n=29