1. Project HEART- Overview
Stephen LEE. MD
Elizabeth Glaser Pediatric AIDS Foundation
presenting for the Project HEART Team

2. The Elizabeth Glaser Pediatric AIDS Foundation
Our 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 USAID funded PMTCT CTA program initiated in 2002
CDC funded Project HEART care and treatment initiated in 2004
Five countries, low-to-middle income, Sub-Saharan Africa
- Côte d’Ivoire, South Africa, Zambia, Tanzania
- Mozambique added in Year Three
Goal for PY4: 166, 220 patients on ART by Feb 23, 2008
85% of the target has been reached
Total number ever enrolled into care as of June 30, 2007
246,558 adults, 23,091 children
Total number ever enrolled into ART program as of June 30, 2007
142,249 adults, 11,525 children

4. Countries Involved in Project HEART
Project HEART supports activities in five countries
Côte d’Ivoire
Mozambique
South Africa
Tanzania
Zambia
Côte d’Ivoire
Tanzania
Zambia: Lusaka District
South Africa: 2 major sites in KwaZulu-Natal Province (McCord- Durban; Africa Centre/Hlabisa Hospital and new PortShepstone, Muchison Hospital)
Tanzania: Muhumbili, Morogru, Mawenzi,KCMC in Moshi; Village of Hope in Dadoma Region,Kibong'oto TB Hospital in Arusha Region,
Kitete Regional Hospital in Tabora Region,Tumbi Regional Hospital in Coast Region
Cote d’Ivoire: Abidjan and Hopital General in Sassandra
Mozambique
Zambia
South Africa

5. Project HEART Framework
Comprehensive approach:
Local Leadership
Standard Operating Procedures
Human Resources
Physical Infrastructure
Training
Drug and Health Commodities Management
Laboratory Services
Monitoring and Evaluation
Community Services
Linkages of HIV Programs
Integration in PHC system
HIV Prevention

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

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

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

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

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

11. Project HEART: Patient Enrollment130 36 56 73 92 94
119
144
163
183
CUMULATIVE data by June 30, 2007
Boxed numbers indicate the number of active sites each quarter

12. Antiretroviral Treatment2
Project HEART Cumulative Patient Enrollment
CUMULATIVE data from March 1, 2004 through June 30, 2007
Country
HIV Palliative Care1
Antiretroviral Treatment2
Children
Adults
Total
Zambia
7,453 (7%)
98,749
106,202
4,570 (7%)
61,532
66,102
Cote d'Ivoire
7,537 (9%)
81,437
88,974
2,322 (6%)
38,225
40,547
South Africa
3,978 (12%)
28,621
32,599
2,978 (17%)
14,320
17,298
Tanzania
3,463 (12%)
26,751
30,214
1,477 (10%)
13,016
14,493
Mozambique
(6%)
11,000
11,660
178 (5%)
3,631
3,809
23,091 (9%)
246,558
269,649
11,525 (8%)
130,724
142,249
All sites report on pediatric care and ART in Zambia, South Africa and Mozambique
In Cote d’Ivoire 21/77 sites report pediatric care.
Number of patients living with HIV, ever enrolled in long-term clinical care and support programs.
Of those enrolled, number of patients started on ARV therapy.

13. Project HEART Current Patient Enrollment
All patients CURRENTLY on care and treatment on June 30, 2007
Country
HIV Palliative Care1
Antiretroviral Therapy2
Children
Adults
Total
Zambia
5,814 ( 7%)
77,602
83,416
3,885 (7%)
50,070
53,955
Cote d'Ivoire
1,972 ( 6%)
29,832
31,804
1,554 (6%)
25,324
26,878
South Africa
3,015 ( 18%)
13,893
16,908
2,628 (20%)
10,778
13,406
Tanzania
2,584 (11% )
20,142
22,726
1,184 (10%)
10,484
11,668
Mozambique
599 ( 6%)
9,629
10,228
155 (5%)
3,165
3,320
13,984 (9% )
151,098
165,082
9,406 (9%)
99,821
109,227
All sites report pediatric care and ART in Zambia, South Africa and Mozambique
In Cote d’Ivoire 21/77 sites report on pediatric care.
Number of HIV-positive patients who received care anytime during April 1st-June 30th 2007.
Number of patients on Treatment on June 30th 2007.

14. One-Year Patients Retention on ART 07/01/06 – 06/30/07
Country
Pts on ART as of
Pts Enrolled on ART, to
Pts No Longer on ART to
Pts on ART as of
ART Retention Rate to
Number of sites
Number of sites
(1)
(2)
(3)
(4)
(5)
(6)
(7)
Cote d'Ivoire
18,234
16,750
8,106
26,878
77% 28 77
South Africa
3,921
12,059
2,574
13,406
84% 10 11
Tanzania
3,720
9,633
1,685
11,668
87% 18 38
Zambia
30,619
34,165
10,829
53,955
83% 40
Total
56,494
72,607
23,194
105,907
82.% 84
166

15. Total Attrition
% of patients who ever started ART at a facility who were not on ART at the end of June 2007

16. Reasons for Attrition Country Stopped Transferred out Died Lost to FU
Unknown
Zambia 4%
36%
28%
16%
Côte d’Ivoire 2% 8%
17%
52%
21%
South Africa 7%
55% 9%
Tanzania 3%
30%
37%
29%
Mozambique
13%
Total
18%
14%

17. Change in Median CD4 Count 6-Month Cohort

18. Change in Median CD4 Count 12-Month Cohort

19. Outcomes after 1 year of ART: Côte d’Ivoire
Retrospective cohort of 10,211 patients on ART at 19 sites in Côte d’Ivoire ( )
First line ARV
ZDV/3TC/EFV (20%)
d4T/3TC/ EFV (22%)
d4T/3TC/NVP (53%)
Median baseline CD4: 123/mm3
Outcome at 12 months
Loss to follow up: 10%
Death rate: 13%
Median time to death: 1.9 month
Survival rate: 77%- 94%
ACONDA/ISPED

20. Pediatric Outcomes after 1 year of ART: South Africa
Retrospective Cohort of 151 children on ART in McCord Hospital, South Africa ( )
Median age: 6 years (Range: )
Median follow-up time: 8 months ( )
Treatment: ARV/CTX
Outcome at 12 month
Median gain in CD4%: 16% (IQR )
12 month survival: 91% (IQR )
MCCord Hospital: BMC Pediatrics 2007, 7:13

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

22. EGPAF PMTCT sites: Project HEART countries (Uptake %, counseling, testing, results; HIV+ among tested)
105%
81%
97%
108%
84%
98%
101%
77%
Break out of cumulative cascade, PH countries
Counseled is often > 100% in many settings, given women are often counseled more than one time.
98%
16%
12%
12%

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

24. Integration of HIV/TB Training of facility health care providers
HIV testing for patients with TB: Côte d’Ivoire 41%; South Africa: 80%
TB screening for HIV-infected patients on ART: South Africa: 80%
ART to HIV-infected patients with TB
Effective integration remains a challenge due to increased work load and limited TB lab capacity

25. Infrastructure, Systems Support Technical Assistance
Renovation of health facilities
Upgrade of laboratories, pharmacies
Human resources
Training, mentoring, supportive supervision
FTE staff, Salary supplement
Technical assistance
Program management
Review of national guidelines
M&E system development
Quality management
PHE/Operations research

26. Trained Health Care Workers
Cumulative from October 1, June 30, 2007
Country
HCW Trained in ART
HCW Trained in non-ART
Physicians
Nurses
Other
Total
Zambia
331
3781
1839
5951
571
Côte d'Ivoire
334 19 83
436
179
South Africa
380
190
1006
859
Tanzania
293
280 89
662 21
Mozambique* NA 92 85
1338
4270
2539
8147
1715
*Mozambique training data includes data from July 1, 2006-June 30, 2007

27. Major Achievements
Strong commitment to working within national guidelines
Comprehensive care and treatment in all countries
In-country partnerships are contributing to national programs
Targets met and exceeded
Strong in-country teams

28. Major Challenges Inadequate public health infrastructure
Limited trained Human Resource
Vast territory e.g. Tanzania, Côte d’Ivoire, Mozambique
Difficult terrain with poor access
Potential for civil unrest
Occasional drug and laboratory supply stock-outs
Limited basic laboratory screening and follow-up of patients; reagent supplies
Pediatric enrollment into care and treatment programs
Integration with PMTCT, TB, MCH programs

29. Sustainability Plan Leadership role in country
Close collaboration with host government
Progressive integration of program into primary health care system
Staff training and mentoring
Development of sub-grantees capacity
Graduation of experienced sites
Ex Côte d’Ivoire ACONDA

30. Future Goals
Increase the number of children enrolled in care and treatment programs
Improve laboratory system
Improve quality of services
Strengthen the Continuum of Care
Public health evaluation/operations research
Documentation of lessons learned

31. Acknowledgements PARTNERS Baylor Nancy Calles Mark Kline
John Snow International
Muka Chikuba
Mike Farabaugh
Andrew Fullum
Lisa Hirschhorn
Vince Masi
University of CA, San Francisco
John Friend
Diane Havlir
Catherine Lyons
USG
Tedd Ellerbrock
Louise Perry
Vivian Walker
Bud Bowen
CDC Staff in Côte d’Ivoire
Mozambique, South Africa
Tanzania, Zambia
CÔTE D’IVOIRE
Xavier Anglaret
Francois Dabis
Joseph Essombo
Catherine Seyler
Anthony Tanoh
Siaka Toure
EGPAF
Georgette Adjorlolo-Johnson
Agbessi Amouzou
Nicole Buono
Charlotte Colvin
Elizabeth Flanagan
Christophe Grundmann
Smita Kumar
Richard Marlink
Rose McCullough
Lulu Oguda
Sara Paque-Margolis
Allison Spensley
Andrea Wahl
Cathy Wilfert
Lee Yerkes
SOUTH AFRICA
Janet Giddy
Helga Holst
Hitesh Hurkchand
Shanila Maharaj
Tshiwela Neluheni
Okey Nwanyanwu
Celicia Serenata
TANZANIA
Christy Gavitt
Anja Giphart
Werner Schimana
Mark Swai
Denis Tindyebwa
Stefan Wiktor
ZAMBIA
Carolyn Bolton
Marc Bulterys
Deborah Conner
Stewart Reid
Moses Sinkala
Elizabeth Stringer
Jefferey Stringer
What to do with USG – make it CDC? Anyone else that needs to go in there?

32. This presentation was made possible through support provided by the U
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

34. NRTI-Induced Lactic Acidosis South Africa
Cohort of 891 patients on ART at McCord Hospital, South Africa ( )
Median baseline CD4 count: 132 cells/mm3 (43-173)
Follow up time: 18 months
Incidence of lactic acidosis: 14/891
ART regimen: d4T+ 3TC EFV/NVP
All female
Median age 36 years (IQR 35-39)
Median weight: 81kg (IQR 69-97)
Median time: 7.5 months (IQR 7-12)
Median peak lactate level: 9.3 mmol/l
Fatal cases: 4 (29%)
McCord Hospital, South Africa 2006; S Afr Med; 96: