1. The Implementation of the WHO Asia Pacific Treatment Metrics Dr. YU, Dongbao WHO Regional Office for the Western Pacific 20 July, 2014 Antiretroviral Treatment Roll-out in Asia: Using Big Data to Inform Policy SUSA39, IAC Melbourne, 20 July 2014

2. 2 |2 | World Health Organization Western Pacific Region Why Metrics for the HIV cascade? WHO Metrics: objective, principles, conceptual framework and indicators? How to use the guide? Examples of country implementation Next steps Outline of presentation

3. Why metrics? What is a cascade? Evaluate the prevention and treatment benefit of ART Provide information to improve HIV services “…What is measured gets done” Dr. M. Chan, DG, WHO To achieve the outcome of viral suppression, each must progress along the continuum of care in a timely manner Delay and attrition contribute to mortality and HIV transmission

4. 4 |4 | World Health Organization Western Pacific Region Major features: Country needs, country led Developed by WHO WPRO/SEARO and supported by CDC, USAID and other partners Field tested in several countries Minimum number of indicators: cascade & program Step by step guidance on presentation, analysis and use of data

5. 5 |5 | World Health Organization Western Pacific Region Objectives and target audience Objectives: To assess and improve the effectiveness of HIV testing, linkages, and retention along the cascade of HIV, TB/HIV and PMTCT services at national and subnational levels; and To assist country program in prioritizing key indicators to monitor the cascade of HIV services from HIV testing to linkages to care and treatment. Target audience: Program managers, staff and, Monitoring and Evaluation officers at national and subnational levels.

6. 6 |6 | World Health Organization Western Pacific Region Guiding principles Public health approach Minimum number of indicators: 13 cascade & 8 programme indicators National and subnational level use Adaptation according to local context Data use and action at all levels

7. % of pre-ART patients retained in care % of pre-ART patients retained in care Diagnosis Enrollment in Care Antiretroviral Treatment Outcome (Viral suppression or MTCT) Linkage to care Retention CASCADES % of PLHIV enrolled in care PROGRAMME CONCEPTUAL FRAMEWORK % of ART patients retained in care Ratio (or %) of # PLHIV newly enrolled in care to # newly diagnosed CONTINUUM OF CARE PMTCT % of TB patients tested for HIV % of TB patients tested for HIV TB-HIV HIV % of PLHIV who know their status % of pregnant women tested for HIV % of pregnant women tested for HIV % of eligible PLHIV receiving ART % of eligible PLHIV receiving ART % of incident TB-HIV cases treated for TB & HIV % of HIV-exposed infants tested within 2 months of birth % of HIV-positive pregnant women whose partner has been tested CD4 count at time of enrollment % of key populations (SW, MSM, PWID) tested for HIV % of PLHIV enrolled in care whose partner has been tested % of months in reporting period with no ARV stock outs % of on time drug pick up % of PLHIV initiating ART within 30 days of eligibility % of pregnant women with HIV who receive ARV drugs during pregnancy % of HIV-exposed infants who receive ARV prophylaxis % of PLHIV on ART with undetectable VL % of PLHIV on ART with undetectable VL % of tested HIV-exposed infants who are HIV-positive

8. What are the indicators? Aware of HIV status Uptake of HIV testing by: TB patients; pregnant women Uptake of HIV testing by KP (SW, MSM, PWID); partners; EID Linkage to HIV care and prevention HIV testing Eligibility assessment Pre-ART care Retention Enrolment in care Lifelong ART: Retention Adherence Supplies ART Initiation Viral suppression / MTCT Ratio of newly enrolled to newly diagnosed Retention in pre- ART care CD4 count at enrolment Coverage of ART (overall, TB/HIV and PMTCT) Retention on ART Timely initiation of ART On-time drug pick-up ARV stock out Viral load suppression HIV+% infants

9. 9 |9 | World Health Organization Western Pacific Region  Uses routine monitoring data at local level, plus estimation data at national level  Some indicators could be adapted  Use visualized graphic presentation of: HIV services with cumulative cross sectional data and/or cohort data Cascade for TB/HIV services Cascade for PMTCT Dashboard How to use the guide (1)

10. 10 | World Health Organization Western Pacific Region  Triangulate with other data sources when possible  Electronic data collection system with unique identifiers improves tracking of cascade of services Analyse Identify Take Triangulate Gaps Action How to use the guide (2)

11. 1) Lack of unique identifier codes, unclear No. PLHIV, loss to follow up in care significant 2) Very few people get viral load test 3) Questionable viral suppression rate? Action taken: 1.Establish UIC 2.Intensify follow up in care 3.Improve viral load test Action taken: 1.Establish UIC 2.Intensify follow up in care 3.Improve viral load test

12. Country Implementation example 2: Cascade of HIV service 2009-2013 Lao PDR Action taken: Presented in June 2014, and to be used by programme review in Aug. 2014. Major findings: 1.HIV testing and ART increasing 2.Lack of UIC, and linkage of PLHIV diagnosis and care weak 3.Viral load testing increasing, but still not enough. 1. 2.

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15. 15 | World Health Organization Western Pacific Region Country implementation example 3: Cascade of HIV services in the Philippines (2009-13) 2 Action: Results presented to the national programme review

16. TB/HIV services in the Philippines (2009-13)

17. 17 | World Health Organization Western Pacific Region A useful tool with promising results Countries are encouraged to use at national and subnational levels Actions are needed to improve the cascade of services Some countries with significant data gaps and need to be addressed Conclusions

18. Next steps  Advocacy : with partners on the use of the Asia Pacific Treatment Metrics  Training : Workshop to be organized by WHO with technical partners for analysis and use of cascade data  Publication : Publish a WPRO progress report on cascade of HIV services, identify the major gaps for HIV, TB/HIV and PMTCT services, as well as gaps in data; and highlight actions needed

19. Acknowledgement Government partners from Cambodia, Viet Nam, China, Indonesia and Myanmar for their leadership and support Celine Daly and Tobi Saidel Ying-ru Lo, Shweta Dhawan, Masami Fujita, Masaya Kato, Nicole Seguy, Zhang Lan, Razia Pendse, Oscar Barreneche and colleagues from WHO, UNAIDS, CDC, USAID, FHI360 Members of the Technical Advisory Group

20. 20 | World Health Organization Western Pacific Region Thank you! Contact: Dongbao Yu Email: yud@wpro.who.int