1. ICAP Track 1.0 Year 6: Reaching Targets Focus on Quality Continued Innovations David Hoos, MD, MPH Dar es Salaam August 4, 2009

2. ICAP/Columbia University In Africa

3. Measurement: ICAP Program and Facility Characteristics Tracking System (PFaCTS) A survey tool for site characteristics to monitor and guide implementation

4. ICAP Unified Reporting System (URS)

6. Reaching Targets

7. Ethiopia Lesotho, Rwanda, S. Africa, Tanzania Mozambique Nigeria, Zambia Cote d’Ivoire 436 sites 613,005 in care Cumulative enrollment in HIV care and treatment programs (436 sites) I 298,668 on ART Number of patients Number of facilities Swaziland

8. Cumulative pediatric enrollment in HIV care programs (436 sites) 436 sites 28,031 on ART Number of patients Number of facilities 63,364 in care Lesotho, Rwanda, S. Africa, Tanzania Mozambique Nigeria, Zambia Cote d’Ivoire Ethiopia Swaziland

9. Magnitude of new enrollment per half year continues to rise Number of patients

10. Children represent 10% and women 59% of those enrolled in care (cumulative to March 2009) % patients in HIV care n=36,875 n= 42,097 n=613,005 n=2,605 n=71,370 n=41,916 n=51,169 n=79,908 n=72,050 n=10,073 n=176,425 n=35,517

11. % patients on ART Children represent 9% and women 58% of patients initiating ART (cumulative to March 2009) n=18,096 n= 35,174 n=298,668 n=1,585 n=20,399 n=22,989 n=32,227 n=41,022 n=42,344 n=4,098 n=22,996 n=57,338

12. Increasing numbers of pregnant women counseled, tested & receive ART for PMTCT # of Women

13. Increasing number of individuals counseled and tested over time # Persons

14. Focus on Quality

15. Indicators of Quality I. Providing Comprehensive Services

16. Most ICAP-supported sites offer comprehensive HIV-related clinical services % sites with services Source: ICAP PFACTS, July 2008

17. Increasing proportion of ICAP-supported sites offering supportive services % of sites Source: ICAP PFACTS, July 2008

18. Diverse prevention services offered at most ICAP-supported sites % sites Source: ICAP PFACTS, July 2008

19. High proportion of ICAP-supported sites provide access to key laboratory assays % sites

20. Indicators of Quality II. TB screening in newly enrolled patients Evidence of TB/HIV Integration

21. n=17,762 n=18,753 New HIV patients n=23,142 n=24,705 n=33,013 n=29,319 n=32,731 Increasing proportion of sites offer TB screening & substantial proportion of patients screened % of patients

22. Persistent focus on TB/HIV integration by ICAP clinical advisors ‘pays off’ over time

23. Indicators of Quality III. Uptake of combination regimens for PMTCT

24. n=2,247n=2,536n=2,931 n=3,966 n=3,587 n=1,216 n=1,932 n=3,739 Successful shift to combination PMTCT regimens at ICAP-supported sites % of Women

25. Rapid shift in maternal regimens for pMTCT: ICAP - Ethiopia New national ART prophylaxis guidelines implemented SD/NVP only SD/NVP & AZT HAART

26. Rapid shift in infant regimens for PMTCT: ICAP- Ethiopia New national ART prophylaxis guidelines implemented SD/NVP & AZT SD/NVP only

27. Indicators of Quality IV. Patient monitoring

28. Robust increases in median CD4+ cell counts noted among cohorts of patients initiating ART CD4 Cell Count (cells/ul) n=7,759 n=5,712 10,581 n=22,936 n=9,162 n=7,682 n=7,153 n=97,163 n=26,178

29. Indicators of quality V. Retention in care

30. Of 299,000 patients initiated ART, 81% continued ART *Includes patients who transferred out while on ART..59% per year on ART 5.2% per year on ART 9.5% per year on ART

31. Loss to follow-up more likely in first 6 months after ART initiation (ICAP-Kenya) Time since ART initiation (Months) # at risk% Died % Lost to follow-up % Lost to program 37,6351.87.99.6 66,6902.49.812.0 125,1273.112.715.4 183,8623.814.117.4 2426984.515.419.2

32. Indicators of quality VI. ART adherence ICAP supported TRAC PHE in Rwanda ICAP supported sites 40% of total sample

33. High 30-day self-reported adherence in Rwandan national ART program sample N=575 N=489N=352 % of patients

34. N=335 N=285 N=222 Large proportion of patient with suppressed HIV RNA in Rwanda national program sample % of patients

35. Self-reported adherence consistent with HIV RNA suppression N=335 N=285 N=222 P<0.05

36. Innovations Continue

37. Strengthening TB Screening South Africa

38. Offering HIV testing to Male Partners of Women in Labor & Delivery Wards– ICAP-Ethiopia

39. Prevention for Most at Risk Populations – Injection drug users in Zanzibar ICAP-Tanzania

40. Services for Special Populations – Prisoners ICAP- Cote d’Ivoire

41. Non – Traditional Providers ICAP-Nigeria

42. Mobile Counseling and Testing in Rural Areas ICAP-Ethiopia

43. Laboratory Systems – Motorcycle Transport ICAP-Tanzania

44. Expansion of Health Workforce – Nursing Multi-country

45. Patient Empowerment through Income Generating Activities ICAP-Nigeria

46. Care for Healthcare Workers with HIV ICAP-Kenya

47. Summary Sites continue to be supported to provide comprehensive services & expanded enrollment Focus on quality: –Expanded menu of clinical and supportive services –Integration of services –Incorporation of new knowledge –Quality indicators Continued innovations

48. Acknowledgements ICAP country directors and their teams Ida Viho - CD Cote d’Ivoire Zenebe Melaku – CD Ethiopia Mark Hawken CD Kenya Josue Lima CD Mozambique Bola Oyeledun CD Nigeria Ruben Sahabo CD Rwanda Tshi Neluheni CD South Africa Amy Cunningham CD Tanzania ICAP-NY Ministries of Health, provincial, district authorities, facility leadership & staff Partner organizations PLHIV organizations CDC leadership and staff