3.5 Years of Track 1.0 at the International Center for AIDS Care and Treatment Programs (ICAP)

September 24-26, 2007Atlanta, GeorgiaDavid Hoos, MD, MPH

• Enrollment, Sites, Outcomes– Care and Treatment– PMTCT and TB/HIV

• Highlighted Activities: – Regionalization, Decentralization– Task Shifting– Community Testing

52168

74551

97144

124253

146470

185903

229735

286,203

26331

87746

108394

131647

9259

5517

22018 36496

2494 1722110089

73444071

72357

5840645986

0

50000

100000

150000

200000

250000

300000

350000

Jul-Sep2004

Oct-Dec2004

Jan-Mar2005

Apr-Jun2005

Jul-Sep2005

Oct-Dec2005

Jan-Mar2006

Apr-Jun2006

Jul-Sep2006

Oct-Dec2006

Jan-Mar2007

Apr-Jun2007

Quarter

Nu

mb

er

of

pa

tie

nts

Kenya, Rwanda, S. Africa, Tanzania

HIV care (pre-ART and ART)

ART care

Mozambique

Ethiopia

Nigeria, Swaziland, Zambia

Cumulative enrollment in HIV care (pre-ART and ART) & ART care at ICAP-supported sites, July 2004 - June 2007

Lesotho

Cumulative pediatric enrollment in HIV care (pre-ART and ART) & ART care at ICAP-supported sites, July 2004 - June 2007

1054567

29584153

55666875

9509

13322

16398

19955

24722

30682

200 353 753 1060 15522041

43825553

67308000

9460

11901

0

5000

10000

15000

20000

25000

30000

Jul-Sep2004

Oct-Dec2004

Jan-Mar2005

Apr-Jun2005

Jul-Sep2005

Oct-Dec2005

Jan-Mar2006

Apr-Jun2006

Jul-Sep2006

Oct-Dec2006

Jan-Mar2007

Apr-Jun2007

Nu

mb

er

of

pa

tie

nts

HIV care (pre-ART and ART)

ART careMozambique

Ethiopia

Lesotho

Nigeria, Swaziland, Zambia

Kenya, Rwanda, S. Africa, Tanzania

239

45

158133

27 31

121104

285

0

50

100

150

200

250

300

Care &treatment

HIVtesting for

TB pts

TBscreeningfor HIV pts

PMTCT PMTCT+ EID PICT/VCT Lab Total sites

Type of activity

Nu

mb

er

of

sit

es

Source: ICAP Site Census, August 2007

Number of ICAP/CU-supported sites by activity, August 2007

40%35%

10% 12%

60% 60%

0%

10%

20%

30%

40%

50%

60%

70%

CD4 CD4 percent HIV-RNA Infantdiagnosis/

PCR

Liver test Bloodchemsitry

Availability and comprehensiveness ofon-site laboratory services at ICAP-supported care

and treatment facilities (n=162)

Source: P-FaCTS January 2007

4

0 1 2

5

1 0

65

13

2426

8

2

7 6

12

8

51

17

0

10

20

30

40

50

60

Ethiopia Kenya Lesotho Mozambique Nigeria South Africa Tanzania

per/

1000 p

ati

en

ts o

n A

RT

Physicians Nurses Other staff

Number of providers per 1000 patients on ART at ICAP-supported care and treatment facilities (n=162)

Source: P-FaCTS January 2007

57% 56% 49% 46% 42% 41% 37% 31% 30%42%

43% 44% 51% 54% 58% 55% 63% 69% 70%58%

0%

20%

40%

60%

80%

100%

ART Pre-ART

n=35,593 n=26,827 n=9,184 n=24,716 n=4,618 n=14, 786

Cumulative enrollment in pre-ART vs. ART care at ICAP-supported sites by country as of June 2007

(Total in care = 286,203)*

n=36,377 n=85,440 n=286,203n=36,737

*Data not available for Swaziland

Cumulative sex and age distribution of patients On ART at ICAP-supported sites as of June 2007

(Total on ART= 131,647)

Female 15+

60,235, 57%

Children <15 9,870, 9%

Male 15+

35,307, 34%

14% 11%

31%

4%

14%

0.29

0.19

25%

22%

33%

29%

28%

60%

36%

53%

39%

11%10%

27%

25%

38%

28%

22%

43%

72%67%

24%

61% 68%57%

0%

20%

40%

60%

80%

100%

Nu

mb

er

of

pati

en

ts

0-1 year 2-4 years 5-14 years

Cumulative pediatric (< 15) enrollment on ART by age and country at ICAP-supported facilities as of June 2007*

n=836 n=2,203n=1,290 n=1,071n=229n=169n=1,091 n=1,627 n=1,867 n=10,384

*Does not include pediatric patients of unknown age group.

ART regimens in adults at ICAP-supported sites by country, April-June 2007*

1st line regimen

Ethiopia Kenya Lesotho Mozambique Nigeria Rwanda South Africa Tanzania Overall

d4T-3TC-NVP

7233 (54%)

3816

(86%)1603 (36%)

12859

(63%)1951 (54%)

3775 (41%)

2159

(14%)

4396

(71%)

37792

(50%)

d4T-3TC-EFV

2857 (21%)

487

(11%)

614

(14%)

1974

(10%)

107

(3%)

595

(6%)

12315

(81%)

541

(9%)

19490

(26%)

ZDV-3TC-NVP

2206 (16%)

57

(1%)

425

(10%)

792

(4%)1434 (40%)

2258 (24%)

129

(1%)

722

(12%)

8023

(11%)

ZDV-3TC-EFV

1101 (8%)

32

(1%)

189

(4%)

359

(2%)

135

(4%)

750

(8%)

456

(3%)

506

(8%)

3528

(5%)

2nd line regimen

52

(0%)

29

(1%)

1

(0%)

760

(4%)

2

(0%)

129

(1%)

117

(1%)

5

(0%)

1095

(1%)

Unknown7

(0%)

34

(1%)

0

(0%)

3632

(18%)

0

(0%)1751 (19%)

70

(0%)

0

(0%)

5494

(7%)

TOTAL13456 (100%)

4455 (100%)

2832

(100%)

20376

(100%)3629

(100%)9258

(100%)15246

(100%)

6170

(100%)75422 (100%)

Adults 15+ (%)

*Data not available for Swaziland and Zambia

1st line regimen

Ethiopia Kenya Lesotho Mozambique Nigeria Rwanda South Africa Tanzania Overall

d4T-3TC-NVP

161

(18%)

233

(46%)

69

(14%)

525

(25%)

6

(3%)317

(30%)29

(2%)

117

(26%)

1447

(21%)

d4T-3TC-EFV

58

(7%)

129

(26%)

10

(2%)

44

(2%)

6

(3%)

88

(8%)

912

(64%)

15

(3%)

12621

(19%)

ZDV-3TC-NVP

569 (65%)

29

(3%)

44

(9%)

342

(16%)

145

(73%)236

(22%)25

(2%)

283

(62%)

1673

(25%)

ZDV-3TC-EFV

84

(10%)

16

(3%)

3

(1%)

9

(0%)

39

(20%)

91

(9%)

191

(13%)

39

(9%)

472

(7%)

Other**0

(0%)

0

(0%)

0

(0%)

0

(0%)

0

(0%)

0

(0%)

212

(15%)

0

(0%)

212

(3%)

2nd line regimen

0

(0%)

1

(0%)

0

(0%)

33

(2%)

0

(0%)

5

(0%)

45

(3%)

0

(0%)

84

(1%)

Unknown4

(0%)

91

(19%)

0

(0%)

1162

(55%)

3

(2%)

319

(30%)

19

(1%)

0

(0%)

1598

(24%)

Total876

(100%)489

(100%)

126

(100%)

2115

(100%)199

(100%)1056

(100%)1433

(100%)

453

(100%)6747

(100%)

Children (%)

ART regimens in children at ICAP-supported sites by country,April-June 2007*

* Data not available for Swaziland and Zambia** In South Africa, d4T-3TC-LPV/r is also prescribed as a first-line regimen for pediatric patients.

Average median CD4 count (cells/µL) at baseline and 6 and 12 months after ART initiation by country at ICAP-supported sites as of June 2007*

118 11494

166185

116

174

142

291284 290 296

362

326

281

394

319

267

230

325319

217

289

254

0

50

100

150

200

250

300

350

400

450

Ethiopia Kenya Lesotho Mozambique Rwanda South Africa Tanzania Overall

CD

4 ce

ll c

ou

nt

Baseline CD4 6-month CD4 12-month CD4

*CD4 data are for subset of patients. Data not available for Swaziland and Zambia.

Average median CD4 count (cells/µL) increase after 6 and12 months of ART by country at ICAP-supported sites as of June 2007*

151

96

204

117

70

145

92

125

170

194

227

112

94

177

190

166

0

50

100

150

200

250

Ethiopia Kenya Lesotho Mozambique Rwanda South Africa Tanzania Overall

CD

4 ce

ll c

ou

nt

incr

ease

at

6 an

d 1

2 m

on

ths

6 months 12 months

*CD4 data are for subset of patients. Data not available for Swaziland and Zambia.

Reasons for ART discontinuation at ICAP-supported sites as of June 2007*

Continued ART 117,337

81%

Discontinued 19,946

19%

*Does not include patients who transferred out.

LTF/Unknown 62%

Dead 33%

Stopped ART 4%

PMTCTNumber of ICAP-supported PMTCT facilities providing (n=148) and

reporting (n=133) PMTCT indicator data, August 2007

35

20

46

18

29

33

18

35

18

29

0

10

20

30

40

50

Ethiopia Mozambique Nigeria Rwanda Tanzania

Nu

mb

er o

f fa

cili

ties

Sites supported Sites reporting

Source: ICAP Site Census, August 2007

Pregnant women counseled and tested in ANC atICAP-supported PMTCT facilities,

April-June 2007

72%

100% 100%98%

93%

66%

100% 100%

92%

5%

11%

6% 6% 7%

88%

0%

20%

40%

60%

80%

100%

Ethiopia Mozambique Rwanda Nigeria Total

Counseled Tested Seroprevalence1st ANC=8,435 1st ANC=10,090 1st ANC=3,604 1st ANC=33,6481st ANC=11,519

TB/HIVICAP-supported HIV care and treatment facilities providing

(n=170) and reporting (n=131) TB screening indicators, 8/07

38 3837

26

14

11

6

38

35

8

24

10 10

6

0

10

20

30

40

50

Ethiopia Rwanda South Africa Tanzania Mozambique Nigeria Kenya

Nu

mb

er o

f fa

cili

ties

Sites supported Sites reporting

Source: ICAP Site Census, August 2007

26%

58%

80%

56%

45%

11%

26%

32%

11%

56%

10%

17%

0%

20%

40%

60%

80%

100%

Mozambique Nigeria Rwanda Total

Screened Screened positive Diagnosed/Initiated TB treatment

Screening and treatment for active TB in ICAP-supported care and treatment facilities (cascade), April-June 2007

New HIV patients=4401 New HIV patients=2410 New HIV patients=2290 New HIV patients=2238 New HIV patients=11,339

64%

29%

95%

60%

66%

16%

50% 48% 49%

22%

70%

33%

63%

100%

74%

0%

20%

40%

60%

80%

100%

Ethiopia Mozambique Nigeria South Africa Total

Tested HIV-positive Enrolled in care and treatment

HIV testing and linkages with care and treatment in ICAP-supported TB facilities (cascade), April-June 2007

New TB patients=4866 New HIV patients=84 New HIV patients=443 New HIV patients=565 New HIV patients=5,958

International Center for AIDS Care and Treatment Programs

Human Capacity Building in Eastern Cape, South Africa

• With 10% of population HIV infected, there are 102 and 16 nurses and doctors per 100,000 inhabitants respectively and only 5 doctors per 100,000 inhabitants in the rural areas

• The Registered Nurses (RNs) provide the majority of care and treatment services in the Primary Health Care Facilities

• Training on HIV care and treatment services is limited for the PNs

• The hospital based doctors do not routinely provide clinical mentoring at the PHC level

• There are few qualified mid-level cadre of pharmacy staff such as pharmacist assistants.

International Center for AIDS Care and Treatment Programs

Strengthening and Training of Health Care WorkersICAP SA Initiatives

1. Training and Mentoring of Nurses– Post Basic Certificate

Course in Clinical Management of HIV

– Nurse Mentorship Initiative (NMI)

2. Training of Pharmacy Assistants •Picture above: Sister Nyakata of Qobo clinic.

•One of the first Registered Nurse to work with ICAP Clinical nurse mentors

International Center for AIDS Care and Treatment Programs

Post Basic Certificate Course in Clinical Management of HIV

• ICAP in partnership with the Universities of Fort Hare and Stellenbosch pioneered the introduction of a Post-basic Certificate Course in Clinical Management of HIV/AIDS in Adults and Children – Program is being implemented between April 2007 – February 2008 – Course is designed to provide seven 3 to 4-day contact sessions in East

London and one 5-day clinical practicum at Tygerberg Hospital, Cape Town

– 26 Registered nurse midwifes have enrolled into the course– Current plan is to update this course into a masters program in

collaboration with South African Academic and professional Institutions– Stellenbosch University’s newly created Centre for Infectious Diseases

is an implementing partner and has been involved in the design and facilitation of the course

International Center for AIDS Care and Treatment Programs

Nurse Mentorship Initiative (NMI)

• In November 2006 a pilot NMI was initiated in Qaukeni Local service area of Eastern Cape

• Three registered nurses with extensive experience in HIV care and treatment started mentoring and working with the DOH Nurses at the Primary health clinics (PHC)

• In February 2007 ICAP in partnership with the EC nursing schools and the DOH, the NMI was launched to improve quality of HIV service delivery for the local population

• 10 Clinical Nurse Mentors (CNM) were hired by ICAP to facilitate the NMI

• The program focuses on advanced clinical skills for the management of HIV and AIDS

International Center for AIDS Care and Treatment Programs

NMI Strategy

• One year program divided into 2-components:

– On-site program• Initial 2-week training program• Three workshops spread out through the year

– Off-site program• The CNMs participating in the NMI are mentored by

an ICAP nurse practitioner within the PHCs• These CNMs in turn mentor DOH registered nurses at

these same facilities• The registered nurses at site level then mentor the

current staff and any newly deployed nurses

International Center for AIDS Care and Treatment Programs

Role of the Clinical Nurse Mentors (CNMs)

• Review HIV care and treatment guidelines with the ‘Mentees’

• Help the mentees obtain clinical care competencies• Conduct comprehensive patients assessments for care

and treatment in collaboration with the clinician at the PHC

• Help the Mentees establish a medical diagnosis, including psychosocial and cognitive problems.

• Advises on prescribing medication according to standard treatment guidelines and in consultation with supervising doctors or nurses.

• Collaborates with DOH on continuing education programs to ensure current knowledge of procedures, protocols, and clinical care issues

• Provides feedback on quality improvement and participates in implementing clinic-wide performance improvement measures

International Center for AIDS Care and Treatment Programs

Training of Pharmacist Assistants

• The South Africa National Department of Health’s Human Resource plan for Health (HRH) underscores the need for continued training and skill development as a staff retention strategy

• In Port Elizabeth, ICAP is supporting a total of 9 primary health clinics (PHCs) managed by the Eastern Cape Department of Health and the Nelson Mandela Metropolitan Municipality– These 9 PHCs share the services of one registered pharmacist,

with very few qualified mid-level cadre of pharmacy staff such as pharmacist assistants

• ICAP in July-August 2007 begun supporting a ‘Task-Shifting’ strategy that will result in the increase in the number of qualified pharmacists assistants

International Center for AIDS Care and Treatment Programs

Pharmacist Assistants Training Program

• A basic pharmacist assistant 12 month apprenticeship course was designed for ICAP by the Frais Health Management Training and the Nelson Mandela Metropolitan University

• Learning process entails 6 - 10 days contact training, distance learning via correspondence, with a registered South Africa Pharmacy Council tutor providing regular mentorship and supervision

• Through a partnership with the provincial and local department of health, ICAP has managed to provide the trainees with tutors at the health facilities where training will take place

• ICAP has already selected and hired 7 Pharmacist assistant trainees who will remain working in the supported health facilities whilst they continue with their training programme

• This approach to training of pharmacist assistants is in the process of being replicated across other ICAP-South Africa supported regions in the Eastern Cape.

Utilizing PLWHA to Increase HIV Testing in Families in Rwanda

• More than 800 of associations in Rwanda; estimated 29,000 active members

• Coordinated nationally by the National Association of PLHA (RRP+) and regionally by RRP+ Regional coordinator

• Monthly meetings provide emotional and social support to members

• Concern that some PLWHA association members are “presumed” HIV+, but have never been tested

• Associations members are untapped human resource for HIV/AIDS programs in Rwanda

Rationale for New Strategy

• Family members of those in HIV care often have not been tested, and don’t participate in Associations

• Associations can be used to identify discordant couples, and also focus on PwP

• Associations are motivated to support their membership, and thus are a resource for VCT outreach and assuring links to C&T for those testing positive

Overall Goals

• To increase access to HIV care and treatment via family approach

• Greater involvement of people living with HIV/AIDS

• Increase early TB case detection and initiation of treatment

Essential steps

• RRP+ and ICAP jointly developed the model

• Two pilot sites were selected:– Kabaya DH and Shyira DH

• Five pilot associations were selected

• 29 Peer Educators and 2 supervising Social Workers were selected

• Peer Educator training developed and held

• Strategy testing pilot phase • “Family Testing Days” were

scheduled weekly at each site• Regular supervision, support and

data collection by 2 ICAP Coordinators

Results from the Pilot Phase

1050 members from 258 families registered 713 (68%) had never had HIV test 649 (91%) tested during the pilot phase

During the 8 family testing days of the pilot phase (Oct 18-Dec 06,07, the following results were achieved:

Kabaya DH:• Total number tested: 358

- Adults: 82 (1 HIV+)- Children: 276 (8 HIV+)

Shyira DH:• Total number tested : 291

- Adults: 131 (7 HIV+)- Children: 160 (1 HIV+)

Kabaya results

Kabaya Hospital: Progression in HIV Testing

0

50

100

150

200

250

Jul Aug Sep Oct Nov

Cli

ents Adults tested

Children tested

Shyira results

Shyira Hospital: Progression in HIV Testing

0

50

100

150

200

250

300

Jul Aug Sep Oct Nov

Cli

ents Adults tested

Children tested