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![Page 1: ICAP Track 1.0 Year 6: Reaching Targets Focus on Quality Continued Innovations David Hoos, MD, MPH Dar es Salaam August 4, 2009.](https://reader036.fdocuments.net/reader036/viewer/2022062322/56649eef5503460f94bffd13/html5/thumbnails/1.jpg)
ICAP Track 1.0 Year 6:
Reaching Targets
Focus on Quality
Continued Innovations
David Hoos, MD, MPHDar es SalaamAugust 4, 2009
![Page 2: ICAP Track 1.0 Year 6: Reaching Targets Focus on Quality Continued Innovations David Hoos, MD, MPH Dar es Salaam August 4, 2009.](https://reader036.fdocuments.net/reader036/viewer/2022062322/56649eef5503460f94bffd13/html5/thumbnails/2.jpg)
ICAP/Columbia University In Africa
![Page 3: ICAP Track 1.0 Year 6: Reaching Targets Focus on Quality Continued Innovations David Hoos, MD, MPH Dar es Salaam August 4, 2009.](https://reader036.fdocuments.net/reader036/viewer/2022062322/56649eef5503460f94bffd13/html5/thumbnails/3.jpg)
Measurement: ICAP Program and Facility Characteristics Tracking System (PFaCTS)
A survey tool for site characteristics
to monitor and guide
implementation
![Page 4: ICAP Track 1.0 Year 6: Reaching Targets Focus on Quality Continued Innovations David Hoos, MD, MPH Dar es Salaam August 4, 2009.](https://reader036.fdocuments.net/reader036/viewer/2022062322/56649eef5503460f94bffd13/html5/thumbnails/4.jpg)
ICAP Unified Reporting System (URS)
![Page 5: ICAP Track 1.0 Year 6: Reaching Targets Focus on Quality Continued Innovations David Hoos, MD, MPH Dar es Salaam August 4, 2009.](https://reader036.fdocuments.net/reader036/viewer/2022062322/56649eef5503460f94bffd13/html5/thumbnails/5.jpg)
![Page 6: ICAP Track 1.0 Year 6: Reaching Targets Focus on Quality Continued Innovations David Hoos, MD, MPH Dar es Salaam August 4, 2009.](https://reader036.fdocuments.net/reader036/viewer/2022062322/56649eef5503460f94bffd13/html5/thumbnails/6.jpg)
Reaching Targets
![Page 7: ICAP Track 1.0 Year 6: Reaching Targets Focus on Quality Continued Innovations David Hoos, MD, MPH Dar es Salaam August 4, 2009.](https://reader036.fdocuments.net/reader036/viewer/2022062322/56649eef5503460f94bffd13/html5/thumbnails/7.jpg)
0
50
100
150
200
250
300
350
400
450
500
0
100,000
200,000
300,000
400,000
500,000
600,000
700,000
Mar-05 Mar-06 Mar-07 Mar-08 Mar-09
HIV Care ART Facilities Currently Reporting
EthiopiaLesotho, 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
Nu
mb
er o
f p
atie
nts
Nu
mb
er of facilities
Swaziland
![Page 8: ICAP Track 1.0 Year 6: Reaching Targets Focus on Quality Continued Innovations David Hoos, MD, MPH Dar es Salaam August 4, 2009.](https://reader036.fdocuments.net/reader036/viewer/2022062322/56649eef5503460f94bffd13/html5/thumbnails/8.jpg)
0
50
100
150
200
250
300
350
400
450
500
0
10,000
20,000
30,000
40,000
50,000
60,000
70,000
Mar-05 Mar-06 Mar-07 Mar-08 Mar-09
HIV Care ART Facilities Currently Reporting
Cumulative pediatric enrollment in HIV care programs (436 sites)
436 sites
28,031 on ART
Nu
mb
er o
f p
atie
nts
Nu
mb
er of facilities
63,364 in careLesotho,
Rwanda,S. Africa, Tanzania
Mozambique
Nigeria,
Zambia
Cote
d’Ivoire
Ethiopia
Swaziland
![Page 9: ICAP Track 1.0 Year 6: Reaching Targets Focus on Quality Continued Innovations David Hoos, MD, MPH Dar es Salaam August 4, 2009.](https://reader036.fdocuments.net/reader036/viewer/2022062322/56649eef5503460f94bffd13/html5/thumbnails/9.jpg)
Magnitude of new enrollment per half year continues to rise
Num
ber
of p
atie
nts
7,682
20,115
33,096
43,978
60,165
67,270
80,732
89,80693,913
1,2265,061
12,90217,061
25,00829,621
34,814
40,679 41,255
0
10,000
20,000
30,000
40,000
50,000
60,000
70,000
80,000
90,000
100,000
Oct '04 -Mar '05
Apr '05 -Sep '05
Oct '05 -Mar '06
Apr '06 -Sep '06
Oct '06 -Mar '07
Apr '07 -Sep '07
Oct '07 -Mar '08
Apr '08 -Sep '08
Oct '08 -Mar '09
New Care Enrollment New ART Enrollment
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59%
69% 67% 66%62% 61% 61% 59% 59% 57% 55%
1%
10%4% 3%
7% 7% 11% 11% 9% 11% 11% 9%
99%
0%
50%
100%
Women 15+ Children <15
Children represent 10% and women 59% of those enrolled in care
(cumulative to March 2009)
% p
atie
nts
in H
IV c
are
n=36
,875
n= 4
2,09
7
n=61
3,00
5
n=2,
605
n=71
,370
n=41
,916
n=51
,169
n=79
,908
n=72
,050
n=10
,073
n=17
6,42
5
n=35
,517
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58%
66% 64% 64% 64%61% 60% 58% 58% 56%
53%
1%
9%4% 4%
8% 6% 7%11% 10% 10% 9% 7%
98%
0%
50%
100%
Women 15+ Children <15
% p
atie
nts
on A
RT
Children represent 9% and women 58% of patients initiating ART
(cumulative to March 2009)
n=18
,096
n= 3
5,17
4
n=29
8,66
8
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
![Page 12: ICAP Track 1.0 Year 6: Reaching Targets Focus on Quality Continued Innovations David Hoos, MD, MPH Dar es Salaam August 4, 2009.](https://reader036.fdocuments.net/reader036/viewer/2022062322/56649eef5503460f94bffd13/html5/thumbnails/12.jpg)
Increasing numbers of pregnant women counseled, tested & receive ART for PMTCT
# o
f W
om
en 109,421
128,144
167,076
96%
96%
92%
91%
94%
93%
11% 87% 8%44% 84% 70%
0
20,000
40,000
60,000
80,000
100,000
120,000
140,000
160,000
180,000
Oct 2007 - Mar 2008 Apr - Sept 2008 Oct 2008 - Mar 2009
1st ANC Counseled Tested HIV Positive ART Prophylaxis
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Increasing number of individuals counseled and tested over time
April-June 2008 July-Sep 2008 Oct-Dec 2008 Jan-March 20090
50,000
100,000
150,000
200,000
250,000
300,000
116,620
176,774
252,487239,592
# P
ers
on
s
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Focus on Quality
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Indicators of QualityI. Providing Comprehensive Services
![Page 16: ICAP Track 1.0 Year 6: Reaching Targets Focus on Quality Continued Innovations David Hoos, MD, MPH Dar es Salaam August 4, 2009.](https://reader036.fdocuments.net/reader036/viewer/2022062322/56649eef5503460f94bffd13/html5/thumbnails/16.jpg)
92%85% 88%
83%74%
0%
50%
100%
VCT PMTCT Labor & Delivery
TB Treatment ART Pharmacy
Most ICAP-supported sites offer comprehensive HIV-related clinical services
% s
ites
with
ser
vice
s
Source: ICAP PFACTS, July 2008
![Page 17: ICAP Track 1.0 Year 6: Reaching Targets Focus on Quality Continued Innovations David Hoos, MD, MPH Dar es Salaam August 4, 2009.](https://reader036.fdocuments.net/reader036/viewer/2022062322/56649eef5503460f94bffd13/html5/thumbnails/17.jpg)
Increasing proportion of ICAP-supported sites offering supportive services
23%
35%
49%
93%
16%
28%
41%
68%
96%
20%
30%
43%
70%
98%
39%
0%
50%
100%
Food support for adults
Food support for adults or
children
Outreach Adherence Support
Peer educators
Jan-07 Jul-07 Jul-08
% o
f si
tes
Source: ICAP PFACTS, July 2008
![Page 18: ICAP Track 1.0 Year 6: Reaching Targets Focus on Quality Continued Innovations David Hoos, MD, MPH Dar es Salaam August 4, 2009.](https://reader036.fdocuments.net/reader036/viewer/2022062322/56649eef5503460f94bffd13/html5/thumbnails/18.jpg)
Diverse prevention services offered at most ICAP-supported sites
97% 96%
87%
68%63%
23%
0%
50%
100%
Counseling regarding disclosure
Education on behavior and
safe sex
Provision of condoms
Referral for on-site screening
for STIs
Education on high-risk
substance abuse
Screening for drug and
alcohol abuse
% s
ites
Source: ICAP PFACTS, July 2008
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35%48% 45%
32%
4% 6%
60%47% 48%
58%
78%
32%
0%
50%
100%
CD4 count Blood Chemistry
LFT CD4 percent
Infant Diagnosis /
PCR
HIV-RNA
Available On-Site Available Off-Site
High proportion of ICAP-supported sites provide access to key laboratory assays
% s
ites
![Page 20: ICAP Track 1.0 Year 6: Reaching Targets Focus on Quality Continued Innovations David Hoos, MD, MPH Dar es Salaam August 4, 2009.](https://reader036.fdocuments.net/reader036/viewer/2022062322/56649eef5503460f94bffd13/html5/thumbnails/20.jpg)
Indicators of QualityII. TB screening in newly enrolled patients
Evidence of TB/HIV Integration
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53%
63% 64%69%
63%67%
64%
0
200
400
0%
50%
100%
Sep-07 Dec-07 Mar-08 Jun-08 Sep-08 Dec-08 Mar-09
% Screened # Sites Reporting
n=17,762 n=18,753New 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
% o
f p
atie
nts
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Persistent focus on TB/HIV integration by ICAP clinical advisors ‘pays off’ over time
Mar-07 Jun-07 Sep-07 Dec-07 Mar-08 Jun-080%
50%
100%
44% 44%
55% 57%
63%
76%
![Page 23: ICAP Track 1.0 Year 6: Reaching Targets Focus on Quality Continued Innovations David Hoos, MD, MPH Dar es Salaam August 4, 2009.](https://reader036.fdocuments.net/reader036/viewer/2022062322/56649eef5503460f94bffd13/html5/thumbnails/23.jpg)
Indicators of Quality
III. Uptake of combination regimens for PMTCT
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37% 41%36% 36% 33%
29%22%
11%
48%47% 56% 51% 53% 60%
66%77%
15% 12% 8% 12% 13% 12% 12% 11%
0%
50%
100%
Jun-07 Sep-07 Dec-07 Mar-08 Jun-08 Sep-08 Dec-08 Mar-09
sd-NVP Multi-Drug Regimen initiated ART
n=2,247 n=2,536 n=2,931 n=3,966 n=3,587n=1,216 n=1,932 n=3,739
Successful shift to combination PMTCT regimens at ICAP-supported sites
% o
f W
om
en
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Rapid shift in maternal regimens for pMTCT: ICAP - Ethiopia
0%
50%
100%
Jan-07 Apr-07 Jul-07 Oct-07 Jan-08 Apr-08
% o
f P
atie
nts
SDNVP only SDNVP+AZT HAART
New national ART prophylaxis
guidelines implemented
SD/NVP onlySD/NVP & AZT
HAART
![Page 26: ICAP Track 1.0 Year 6: Reaching Targets Focus on Quality Continued Innovations David Hoos, MD, MPH Dar es Salaam August 4, 2009.](https://reader036.fdocuments.net/reader036/viewer/2022062322/56649eef5503460f94bffd13/html5/thumbnails/26.jpg)
Rapid shift in infant regimens for PMTCT: ICAP- Ethiopia
0%
50%
100%
Apr-07 Jul-07 Oct-07 Jan-08 Apr-08
% o
f P
ati
en
ts
SDNVP only SDNVP+AZT
New national ART prophylaxis
guidelines implemented
SD/NVP & AZTSD/NVP only
![Page 27: ICAP Track 1.0 Year 6: Reaching Targets Focus on Quality Continued Innovations David Hoos, MD, MPH Dar es Salaam August 4, 2009.](https://reader036.fdocuments.net/reader036/viewer/2022062322/56649eef5503460f94bffd13/html5/thumbnails/27.jpg)
Indicators of Quality IV. Patient monitoring
![Page 28: ICAP Track 1.0 Year 6: Reaching Targets Focus on Quality Continued Innovations David Hoos, MD, MPH Dar es Salaam August 4, 2009.](https://reader036.fdocuments.net/reader036/viewer/2022062322/56649eef5503460f94bffd13/html5/thumbnails/28.jpg)
146
198
165 161
137 136124
115106
280
313 314
284 288
264 263 256
227
318
353345 342 345
316
287 291279
0
50
100
150
200
250
300
350
400
Overall Rwanda Mozambique Nigeria Tanzania Lesotho Ethiopia South Africa Kenya
Baseline 6-Month 12-Month
Robust increases in median CD4+ cell counts noted among cohorts of patients initiating ART
CD
4 C
ell
Co
unt (
cells
/ul)
n=7,759 n=5,712 10,581n=22,936n=9,162
n=7,682n=7,153n=97,163
n=26,178
![Page 29: ICAP Track 1.0 Year 6: Reaching Targets Focus on Quality Continued Innovations David Hoos, MD, MPH Dar es Salaam August 4, 2009.](https://reader036.fdocuments.net/reader036/viewer/2022062322/56649eef5503460f94bffd13/html5/thumbnails/29.jpg)
Indicators of qualityV. Retention in care
![Page 30: ICAP Track 1.0 Year 6: Reaching Targets Focus on Quality Continued Innovations David Hoos, MD, MPH Dar es Salaam August 4, 2009.](https://reader036.fdocuments.net/reader036/viewer/2022062322/56649eef5503460f94bffd13/html5/thumbnails/30.jpg)
Continued ART*243,285
81%
Discontinued ART, 55,383 19%
Stopped ART 5%
Reported Dead 34%
Lost to Follow-up 62%
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
![Page 31: ICAP Track 1.0 Year 6: Reaching Targets Focus on Quality Continued Innovations David Hoos, MD, MPH Dar es Salaam August 4, 2009.](https://reader036.fdocuments.net/reader036/viewer/2022062322/56649eef5503460f94bffd13/html5/thumbnails/31.jpg)
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
3 7,635 1.8 7.9 9.6
6 6,690 2.4 9.8 12.0
12 5,127 3.1 12.7 15.4
18 3,862 3.8 14.1 17.4
24 2698 4.5 15.4 19.2
![Page 32: ICAP Track 1.0 Year 6: Reaching Targets Focus on Quality Continued Innovations David Hoos, MD, MPH Dar es Salaam August 4, 2009.](https://reader036.fdocuments.net/reader036/viewer/2022062322/56649eef5503460f94bffd13/html5/thumbnails/32.jpg)
Indicators of qualityVI. ART adherence
ICAP supported TRAC PHE in RwandaICAP supported sites 40% of total sample
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High 30-day self-reported adherence in Rwandan national ART program sample
77.6 76.7 76.2
11.3 11.7 12.7
18.1 18.6 21.2
0%
50%
100%
6 months 12 months 18 months
100% adherent 90% adherent ≤80% adherent
N=575 N=489 N=352
% o
f p
atie
nts
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83.3 81.8 83.8
9.9 9.8 8.16.9 8.4 8.1
0%
50%
100%
6 months 12 months 18 months
Undetectable/< 40 cp/ML 40 - 500 cp/ML > 500 cp/ML
N=335 N=285 N=222
Large proportion of patient with suppressed HIV RNA in Rwanda national program sample
% o
f p
atie
nts
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Self-reported adherence consistent with HIV RNA suppression
84 84 8577
6273
0%
50%
100%
6 months 12 months 18 months
% w
ith
un
det
ecta
ble
vir
al l
oad
100% adherent <100% adherent
N=335 N=285 N=222
P<0.05
![Page 36: ICAP Track 1.0 Year 6: Reaching Targets Focus on Quality Continued Innovations David Hoos, MD, MPH Dar es Salaam August 4, 2009.](https://reader036.fdocuments.net/reader036/viewer/2022062322/56649eef5503460f94bffd13/html5/thumbnails/36.jpg)
Innovations Continue
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Strengthening TB ScreeningSouth Africa
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Offering HIV testing to Male Partners of Women in Labor & Delivery Wards–
ICAP-Ethiopia
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Prevention for Most at Risk Populations – Injection drug users in Zanzibar
ICAP-Tanzania
![Page 40: ICAP Track 1.0 Year 6: Reaching Targets Focus on Quality Continued Innovations David Hoos, MD, MPH Dar es Salaam August 4, 2009.](https://reader036.fdocuments.net/reader036/viewer/2022062322/56649eef5503460f94bffd13/html5/thumbnails/40.jpg)
Services for Special Populations – Prisoners
ICAP- Cote d’Ivoire
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Non – Traditional ProvidersICAP-Nigeria
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Mobile Counseling and Testing in Rural Areas ICAP-Ethiopia
![Page 43: ICAP Track 1.0 Year 6: Reaching Targets Focus on Quality Continued Innovations David Hoos, MD, MPH Dar es Salaam August 4, 2009.](https://reader036.fdocuments.net/reader036/viewer/2022062322/56649eef5503460f94bffd13/html5/thumbnails/43.jpg)
Laboratory Systems – Motorcycle Transport
ICAP-Tanzania
![Page 44: ICAP Track 1.0 Year 6: Reaching Targets Focus on Quality Continued Innovations David Hoos, MD, MPH Dar es Salaam August 4, 2009.](https://reader036.fdocuments.net/reader036/viewer/2022062322/56649eef5503460f94bffd13/html5/thumbnails/44.jpg)
Expansion of Health Workforce – NursingMulti-country
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Patient Empowerment through Income Generating Activities
ICAP-Nigeria
![Page 46: ICAP Track 1.0 Year 6: Reaching Targets Focus on Quality Continued Innovations David Hoos, MD, MPH Dar es Salaam August 4, 2009.](https://reader036.fdocuments.net/reader036/viewer/2022062322/56649eef5503460f94bffd13/html5/thumbnails/46.jpg)
Care for Healthcare Workers with HIV ICAP-Kenya
![Page 47: ICAP Track 1.0 Year 6: Reaching Targets Focus on Quality Continued Innovations David Hoos, MD, MPH Dar es Salaam August 4, 2009.](https://reader036.fdocuments.net/reader036/viewer/2022062322/56649eef5503460f94bffd13/html5/thumbnails/47.jpg)
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
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Acknowledgements
ICAP country directors and their teamsIda Viho - CD Cote d’IvoireZenebe Melaku – CD EthiopiaMark Hawken CD KenyaJosue Lima CD MozambiqueBola Oyeledun CD NigeriaRuben Sahabo CD RwandaTshi Neluheni CD South Africa
Amy Cunningham CD TanzaniaICAP-NY Ministries of Health, provincial, district authorities, facility leadership & staffPartner organizationsPLHIV organizationsCDC leadership and staff