1. Project HEART- Overview Track 1.0 Meeting 2008 Andrea Wahl, BSN, MPH Elizabeth Glaser Pediatric AIDS Foundation presenting for the Project HEART Team

2. Elizabeth Glaser Pediatric AIDS Foundation Mission: The Elizabeth Glaser Pediatric AIDS Foundation seeks to prevent pediatric HIV infection and to eradicate pediatric AIDS through research, advocacy, and prevention and treatment programs.

3. Program Overview PMTCT “Call to Action” program initiated in 2000 with private funds, USAID started funding CTA in 2002. CDC-funded HIV care and treatment program “Project HEART” initiated in 2004 Five countries, low-to-middle income, Sub-Saharan Africa –Cote d’Ivoire, South Africa, Tanzania, Zambia –Mozambique added in Program Year Three (PY3) Goal for PY5: 257,475 patients ever on ART by Feb 28, 2009 79% of the target has been reached as of March 30, 2008 Total number ever enrolled into care as of March 30, 2008: 374,675 including 28,467 children under 15 Total number ever enrolled into ART program as of March 30, 2008: 204,264 including 15,316 children under 15

4. Project HEART Strategic Framework Family-centered comprehensive health approach that includes: –Engaging local leadership –Collaboration with host governments –Adherence to national treatment guidelines –Decentralization to district and primary health center levels –Innovative human resource approaches such as “task shifting” Decentralization and integration of services within primary care systems are key strategies to improve access and coverage and to ensure local ownership and sustainability.

5. Central Sub-Grantees Baylor University –Pediatric focus –Attachments, in country trainings JSI –QI focus –Helps build capacity for QI at the country, district and site levels UCSF –Training and mentoring

6. Project HEART supports activities in five countries Côte d’Ivoire Mozambique South Africa Tanzania Zambia Côte d’Ivoire Zambia Tanzania South Africa Mozambique Countries Involved in Project HEART

7. Côte d’Ivoire EGPAF-Supported Sites Number of active ART sites in June 2007 = 77

8. Mozambique EGPAF-Supported Sites Number of active ART sites in June 2007 = 17

9. South Africa EGPAF-Supported Sites Number of active ART sites in June 2007 = 11

10. Tanzania EGPAF-Supported Sites Number of active ART sites in June 2007 =38

11. Zambia EGPAF-Supported Sites Number of active ART sites in June 2007 = 40

13. 1.Number of patients living with HIV, ever enrolled in long-term clinical care and support programs. 2.Of those enrolled, number of patients started on ARV therapy. CUMULATIVE data from March 1, 2004 through March 30, 2008 Project HEART Cumulative Patient Enrollment Country HIV Palliative Care 1 Antiretroviral Treatment 2 ChildrenAdultsTotalChildrenAdultsTotal Zambia9,876 (7%)129,937139,8135,953 (7%)82,03187,984 Cote d'Ivoire 3,957 (5%)76,38980,3461,428 (4%)35,58437,012 South Africa7,991 (10%)71,81379,8045,401 (11%)43,01648,417 Tanzania4,973 (10%)42,98847,9612,036 (9%)20,26822,304 Mozambique1,671 (6%)25,08026,571498 (6%)8,0498,547 Total28,468 (8%)346,207374,67511,525 (8%)188,948204,264

14. Project HEART Current Patient Enrollment All patients CURRENTLY on care and treatment on March 30, 2008 Country HIV Palliative Care 1 Antiretroviral Therapy 2 ChildrenAdultsTotalChildrenAdultsTotal Zambia7,034 (7%)101,089108,1234,671 (7%)67,03471,705 Cote d'Ivoire1,662 (6%)27,60329,265976 (4%)24,40825,384 South Africa5,371 (13%)37,42342,7944,950(12%)36,36641,316 Tanzania4,160 (10%)35,65939,8191,635 (9%)16,51418,149 Mozambique831 (6%)12,67513,506454 (6%)7,3937,847 Total19,058 (8%)214,449233,50712,686 (8%)151,715164,401 1.Number of HIV-positive patients who received care anytime January 1- March 30, 2008. 2.Number of patients on ART on March 30 th 2008.

15. Percentage of patients ever started on ART who are children; as of September 2007, December 2007, and March 2008

16. Percent distribution of children ever started on ART, by age group

17. 1 Global and 11 country-specific strategic frameworks in development Seven main objectives were identified for the country-specific frameworks, mirroring the seven key strategies of the WHO implementation document [1] : [1] Strengthen govt. leadership, ownership and accountability for peds C&T Ensure integrated prevention care and treatment of infants and young children provided at all levels including primary health care facilities Enhance identification of HIV-exposed and infected infants Ensure reliable procurement and supply management Expand lab capacity for pediatric HIV and AIDS needs Strengthen community capacity to demand and utilize peds C&T Strengthen M&E of pediatric C&T [1] [1] Meeting Report: Programming framework to support scale-up of HIV related diagnosis, care, support and treatment for HIV- exposed and HIV infected infants and children in resource-constrained settings. UNICEF-WHO, Draft date: December 16, 2007 Pediatric Treatment Frameworks

18. Percentage of patients on ART who are on first line regimens at the end of Jan-Mar 2008, by age group

19. PERCENTAGE DISTRIBUTION OF CHILDREN (0-14 YEARS OLD) ON FIRST-LINE REGIMENS AT THE END OF THE QUARTER, JAN-MAR 2008

20. PERCENTAGE DISTRIBUTION OF ADULTS ON FIRST- LINE REGIMENS AT THE END OF THE QUARTER, JAN-MAR 2008

21. % change in 6 Mo CD4 cohorts

22. Rate of Patient Attrition over the Past Year April 1 2007 – March 31 2008

23. Median attrition in the past year by site characteristics by ownershipby location by health care levelby length of support

24. Number of EGPAF PMTCT sites, Project HEART countries (2004-2007)

25. EGPAF PMTCT sites: Project HEART countries (Uptake %, counseling, testing, results; HIV+ among tested)

26. EGPAF PMTCT sites: Project HEART countries (HIV+, uptake %, Women and Infant ARV)

27. Achievements and Lessons Learned Close collaboration with host government is essential for sustainable programs Staff training and mentoring is necessary; task shifting where appropriate is part of the solution Increasing the pace of integration of program into primary health care system Decentralization of services to lower levels is a current focus –Ex: Tanzania – approx 20 new sites each quarter for past two quarters, rolling out to primary health center and dispensary levels

28. Achievements and Lessons Learned cont. Development of sub-grantee capacity encourages sustainability Transfer of experienced sites to local organizations necessitates adequate timeline, communication and identification (and attainment) of key readiness indicators Strengthening linkages between HIV-related services such as counseling and testing, PMTCT, TB and ART aids in identification and provision of access to those in need of care and treatment

29. General Program Challenges Pediatric access and enrollment Limiting loss to follow up Inadequate public health infrastructure Limited trained human resources Occasional drug, laboratory reagent and supply stock-outs Integration with PMTCT, TB, MCH programs Vast geographic territory and distances Potential for civil unrest

30. Future Goals Focus even more on local capacity building and transition to local partners Increase the number of children enrolled in care and treatment programs Improve laboratory system Improve quality of services Strengthen linkages between services Public health evaluation/operations research and documenting lessons learned

31. CÔTE D’IVOIRE Bruce Struminger Joseph Essombo Anthony Tanoh Siaka Toure Joseph Sylvain N'dah Kouakou Charles Diby Brou EGPAF Georgette Adjorlolo-Johnson Agbessi Amouzou Lisa Bohmer Nicole Buono Elizabeth Flanagan Christophe Grundmann Nick Hellmann Trish Karlin Stephen Lee Richard Marlink Rose McCullough Lulu Oguda Sara Pacque-Margolis Mposo Ntumbanzondo Penny Smith Allison Spensley Andrea Wahl Cathy Wilfert Lee Yerkes EGPAF Staff in Côte d’Ivoire, Mozambique, South Africa, Tanzania, Zambia MOZAMBIQUE Lisa Nelson Cathrien Alons Cameron Garrett Alexandre Boon Caroline de Schacht SOUTH AFRICA Okey Nwanyanwu Celicia Serenata Tshi Neluheni Marriam Mangochi TANZANIA Stefan Wiktor Anja Giphart Denis Tindyebwa Werner Schimana Mark Swai Aisa Muya ZAMBIA Marc Bulterys Deborah Conner Carolyn Bolton Susan Strasser Moses Sinkala Elizabeth Stringer Jefferey Stringer Stewart Reid Mary Morris PARTNERS Baylor Mark Kline Meg Ferris John Snow International Andrew Fullem Lisa Hirschhorn University of CA, San Francisco Diane Havlir Catherine Lyons Royce Lin CDC Tedd Ellerbrock Louise Perry Vivian Walker Bud Bowen CDC Staff in Côte d’Ivoire Mozambique, South Africa Tanzania, Zambia ……..AND ALL OF OUR PATIENTS, PARTNERS, STAFF AND DONORS Acknowledgements

32. This presentation was made possible through support provided by the U.S. Centers for Disease Control and Prevention (CDC), through the President’s Emergency Plan for AIDS Relief (PEPFAR), as part of the Elizabeth Glaser Pediatric AIDS Foundation's International Family AIDS Initiatives (“Project HEART”/Cooperative Agreement No. U62/CCU123451). The opinions expressed herein are those of the authors and do not necessarily reflect the views of CDC.

33. Elizabeth Glaser Pediatric AIDS Foundation