ICAP: SUCCESS AS A TRACK 1.0
IMPLEMENTING PARTNER
November 16, 2011
ABOUT ICAPICAP was founded in 2004 at Columbia University’s Mailman School of Public Health. Now a global leader in HIV/AIDS services, ICAP has supported work at more than 2,000 sites across 21 countries around the world. More than one million people have received HIV services through ICAP-supported programs.
ICAP’s support extends beyond direct provision of HIV services to help improve strategic planning, infrastructure, management, training, clinical mentorship, supportive supervision, quality improvement, laboratories, medical records, pharmacy systems, and monitoring and evaluation.
ORGANIZATIONAL STRUCTURE
ICAP-NY Headquarters• Situated at the Mailman School of
Public Health at Columbia University
• Expertise in program development, implementation, research and student training
• Responsibility for administrative, financial, strategic planning and development functions
Country Programs• Large country teams under
leadership of country directors• Provide national, regional, facility
and community level support• Expertise in capacity building:
program implementation, logistics, clinical issues, laboratory services, administration, financial management, monitoring and evaluation
WHERE ICAP WORKS• Cameroon*• Côte d’Ivoire• Democratic Republic of the Congo• Ethiopia• Dominican Republic*• Kazakhstan• Kenya• Kyrgyzstan• Lesotho• Malawi• Mali• Mozambique• Nigeria
• Rwanda• South Africa• Swaziland• Tajikistan• Tanzania• Thailand*• United States• Uganda*• Zambia
Notes: Bold indicates countries with ICAP offices. * Country ICAP has supported in the past
WHERE ICAP WORKSTUNISIA
MOROCCO
SAHARA
ALGERIA
MAURITANIA
NIGER
LIBYA
CHAD
EGYPT
SUDAN
ETHIOPIA
DJIBOUTI
ERITREA
SOMALIAKENYA
TANZANIA
DEMOCRATIC
CENTRAL
RWANDA
GABON
EQUATORIAL
ANGOLA
CONGO
NIGERIABENIN
D’IVOIRESIERRA
SENEGAL
GHANA
THE
GUINEA
LIBERIA CAMEROON
MALAWI
ZAMBIA
MOZAMBIQUE MADAGASCARZIMBABWE
BOTSWANA
SWAZILANDLESOTHO
NAMIBIA
ANGOLA
WESTERN
UGANDA
OF THE CONGO
REPUBLIC
BURUNDI
GUINEAREP. OF
TOGOCOTE
BURKINAGUINEA
LEONE
GAMBIA
BISSAU
SOUTH
REPUBLIC
AFRICAN
THE
AFRICA
*Denoted by countries in light blue
MADAGASCAR
MALI
OVERVIEW OF ICAP PROGRAM ACCOMPLISHMENTS
ICAP SUPPORTED SERVICES AT THE
FACILITY LEVEL
ICAP SUPPORTED FACILITIES IN KENYA, BY TYPE OF SERVICES
ICAP SUPPORTED HIV COUNSELING AND TESTING IN
MOZAMBIQUE ICAP SUPPORTED LABORATORIES IN ETHIOPIA
Total distinct facilities
Care & treatment
TB screening for HIV pts
HIV testing for TB pts
PMTCT Early infant diagnosis
PICT/VCT Lab0
200
400
600
800
1,000
1,200
1,400
1,600
1,800
1540
530 583
397
1156
858 1,010
548
ACTIVITIES AT TRACK 1.0SUPPORTED FACILITIES, JUNE 30, 2011
Num
ber o
f fac
ilitie
s
Source: ICAP Site Census, June 2011Note: Some facilities offer more than one activity.
ACTIVITIES AT ALL ICAP SUPPORTED FACILITIES,
JUNE 30, 2011
Num
ber o
f fac
ilitie
s
Source: ICAP Site Census, June 2011Note: Some facilities offer more than one activity.
Total distinct facilities
Care & treatment
TB screening for HIV pts
HIV testing for TB pts
PMTCT Early infant diagnosis
PICT/VCT Lab0
500
1,000
1,500
2,000
2,500
2284
763 807
576
1823
1053 1,010
723
ICAP ACCOMPLISHMENTS: HIV CARE AND TREATMENT
• More than 1.3 million patients enrolled into HIV care in ~900 facilities– 650,000 (50%) patients initiated ART
– 56,000 (9%) ART patients were <15 years of age
– 380,000 (71%) of 534,000 patients enrolled in facilities reporting TB screening data were screened for TB at enrollment
38443
38808
39173
39539
39904
40269
40634
0
100,000
200,000
300,000
400,000
500,000
600,000
700,000
800,000
900,000
1,000,000
0
100
HIV Care ART
CUMULATIVE ENROLLMENT IN HIV CARE AND TREATMENT AT FACILITIES EVER
SUPPORTED IN TRACK 1.0
Source: ICAP URS June 2011.Notes: Data are only from clinics supported and reporting. The country arrows depict when the country began contributing data.
*Data for Kenya includes Central Province only.
Num
ber o
f pat
ient
s Number of clinics484,617
on ART
941,819 in care
584clinics
Kenya*,Mozambique
Rwanda,S. Africa, Tanzania
Ethiopia
Nigeria
Côte d’Ivoire
38443
38808
39173
39539
39904
40269
40634
0
200,000
400,000
600,000
800,000
1,000,000
1,200,000
1,400,000
0
100
HIV Care ART
CUMULATIVE ENROLLMENT IN HIV CARE AND TREATMENT AT FACILITIES EVER
SUPPORTED BY ICAP*
Source: ICAP URS June 2011.Notes: The country arrows depict when the country began contributing data. *Does not include facilities funded through the MTCT Plus mechanism.
Num
ber o
f pat
ient
s Number of clinics
649,880 on ART
1,292,079 in care
898clinics
Kenya,Lesotho,
Mozambique Rwanda,S. Africa, Tanzania
Ethiopia
Côte d’Ivoire
Nigeria, ZambiaSwaziland
1/1/20
05
1/1/20
06
1/1/20
07
1/1/20
08
1/1/20
09
1/1/20
10
1/1/20
110%
25%
50%
75%
100%
0
100
200
300
400
500
600
80%, 295
79%, 19384
83%, 95
73%, 20343
Reporting Quarter
Perc
ent r
etai
ned
Number of clinics
SUSTAINED COHORT RETENTION (6 AND 12 MONTHS) AFTER ART INITIATION AT
SUPPORTED FACILITIESTrend : P=0.7299
Trend: P=0.0844
Source: ICAP URS June 2011Note: Significance testing for trend analysis reflects crude RR of retention per 1 unit increase in reporting quarter.
Percent retained 6 monthsPercent retained 12 monthsNumber of clinics reporting cohort data
• 1.8 million pregnant women HIV tested at ANC in ~ 1,700 facilities– 113,000 (6%) women tested positive + 20,000 (1%)
known positive
– 96,000 (72% of all positive) women received ARV prophylaxis, including 12,000 who received triple therapy
ICAP ACCOMPLISHMENTS: PMTCT
39234 39600 39965 40330 406950
50,000
100,000
150,000
200,000
250,000
0
200
400
600
800
1000
1200
1400
1600
1800
ANC visit Tested Number of facilities
NUMBER OF PREGNANT WOMEN ATTENDING ANC AND RECEIVING HIV
TESTING, BY QUARTER
Source: ICAP URS June 2011. The country arrows depict when the country started contributing data.
1,668 clinics
122,011 HIV tests
215,120 ANC visits
Num
ber o
f wom
enN
umber of clinics
S. Africa
Côte d’Ivoire
Mozambique, Rwanda,Ethiopia,Nigeria,Tanzania
Kenya
• 3.7 million people tested for HIV in ~1000 facilities
• 304,154 HIV-infected patients screened for TB-related symptoms upon enrollment into HIV care and treatment.
– 41,577 diagnosed with TB and initiated TB treatment at these facilities
• ~1 million HIV simple rapid tests and ~650,000 CD4 count tests processed in ~500 laboratories
ICAP ACCOMPLISHMENTS: HIV TESTING AND COUNSELING, TB/HIV,
AND LABORATORY SERVICES
KNOWLEDGE MANAGEMENT APPROACHES
Unified reporting system (URS):
• Web-based data system that captures and disseminates routine monitoring data from multiple ICAP-supported activities and programs at ICAP-supported sites
• Automated reports allow for real-time use of data for program monitoring and evaluation
• Technical assistance provided to country programs and MoH to develop similar databases for aggregate data collection, reporting and use
KNOWLEDGE MANAGEMENT TOOLS (1)
Patient-level data warehouse
• Warehouse captures a minimum set of HIV care and treatment and TB screening data elements from diverse country-level patient databases
• Automated reports generated to feedback information to sites on patient characteristics and clinical outcomes
• Technical assistance provided to country programs and MoH to develop and enhance patient level data collection systems for reporting and clinical care
KNOWLEDGE MANAGEMENT TOOLS (2)
ICAP PATIENT-LEVEL DATA WAREHOUSE ELEMENTS
Enrollment Table• Basic
demographic information • Age• Sex• enrollment
date• Prior ARV use• Point of entry• Transfer
Visit Table: Visit date, WHO stage, CD4 count & percent, height, weight, Hb, ALT, next scheduled visit date
Medication and pregnancy Table: ART regimen, regimen start & end date, regimen switch and reason, TB screening date and result, TB, cotrimoxazole, and fluconazole medication dates, Pregnancy status, weeks gestation, due date, actual pregnancy end date
Status Table: Patient disposition status (dead, transferred, withdrew, LTF, stopped ART, etc) and status date
Baseline: 1 rowper patient Follow-up data: 1 row per measure per patient
Currently: 183 facilities, 440,000 patients enrolled in care, and 234,000 initiating ART across 5 countries.
AUTOMATED FEEDBACK REPORTS
Webinars: Quarterly web-based interactive meetings to expand knowledge base and ensure best practices among ICAP staff, as well as other interested stakeholders – Clinical:
• Improving effectiveness of adherence in HIV treatment settings• Rapid initiation of ART/ARV during pregnancy• ART for prevention: Evidence from recent studies
– M&E methodology and data dissemination: • Using aggregate data for program M&E• Basic epidemiologic measures of disease occurrence• Using routinely-collected data to estimate patient retention
DataBytes: Periodic bulletin highlighting results from routine data– Characteristics and outcomes among youth enrolled in ICAP care and treatment facilities
STRATEGIES TO ENHANCE DATA DISSEMINATION AND USE FOR
PROGRAM IMPROVEMENT
HEALTH SYSTEMS STRENGTHENING THROUGH
ICAP SUPPORT
Jan-05 Jul-05 Jan-06 Jul-06 Jan-07 Jul-07 Jan-08 Jul-08 Jan-09 Jul-09 Jan-10 Jul-10 Jan-110
10,000
20,000
30,000
40,000
50,000
ART non-ART palliative care
Num
ber o
f hea
lth w
orke
rs
Source: ICAP URS June 2011
CUMULATIVE NUMBER OF HEALTH WORKERS TRAINED IN ART AND NON
ART PALLIATIVE CARE
Source: ICAP PFaCTS Round 5, June 2011.Note: Laboratory services offered: Within the facility: specimen collection and testing done within this facility.At another facility: specimen collection done within this facility and testing conducted at another facility or both specimen collection and testing are conducted at another facility.
AVAILABILITY OF LABORATORY ASSAYS AT FACILITIES WHERE ICAP SUPPORTS CARE
AND TREATMENT (n=594)
Perc
ent o
f fac
ilitie
s
CD4 count Hemoglobin / Hematocrit
Creatinine Hepatitis B sur-face antigen
Liver enzyme test
Infant diagnosis / PCR
Sputum smear for TB
HIV-RNA0%
50%
100%
26%
65%
32%24% 30%
5%
66%
2%
74%
34%
63%
54%59%
95%
29%
40%
1%5%
22%11% 4%
59%
Available within the facility Available at another facility Not available
INCREASING AVAILABILITY OF PATIENT SUPPORT SERVICES AT ICAP SUPPORTED CARE AND TREATMENT CLINICS (N=248*)
Perc
ent w
ith s
ervic
e
Source: ICAP PFaCTS June 2011. Notes: *Only clinics that submitted all three rounds of data collection are included. ART adherence counseling: Verbal patient education provided by trained personnel at least every 3 months. Outreach: patients who miss clinic follow-up or medication pick up visits are identified and contacted by facility personnel. Nutritional treatment for children and infants: treatment and weaning for severely malnourished children / infants. Nutritional treatment for adults: treatment for severely malnourished adults. Food rations for adults or children: provision of snacks, food packets, or other food rations to promote ART adherence or household food security.
ART adherence counseling Outreach Peer educator program Nutritional treatment for adults
Nutritional treatment for in-fants/children
Food rations for adults or children
0%
50%
100%
90%
48%
40%
19%
29%
13%
98%
78%
71%
36%
56%
25%
99%96%
85%
46%
64%
32%
Jan-08 Jul-09 Jul-10
Sep-08 Dec-08 Mar-09 Jun-09 Sep-09 Dec-09 Mar-10 Jun-10 Sep-10 Dec-10 Mar-11 Jun-110%
50%
100%
41%31%
24% 28%19% 16%
22%12% 8% 5% 8% 6%
49%59%
67%63%
71%70%
65%75% 79%
80%80%
68%
10% 10% 10% 8% 9% 13% 13% 13% 13% 16% 12%
16%
0.1055126792
SD-NVP Multi-drug regimens Initiated ART Already on ART*
n= 3,684 n= 5,133 n = 5,778 n= 7,931 n= 7,990 n= 9,070
INCREASED USE OF MULTI DRUG ARV REGIMENS IN ICAP SUPPORTED PMTCT
PROGRAMS
Perc
ent o
f wom
en
Source: ICAP URS June 2011Notes: Multi-drug regimens prior to April 2011 include AZT/sd-NVP, AZT/3TC tail postpartum, and HAART at 34 weeks.*Central data collection of indicator "HIV+ women already on ART" began in April 2011
Jun-08 Sep-08 Dec-08 Mar-09 Jun-09 Sep-09 Dec-09 Mar-10 Jun-10 Sep-10 Dec-10 Mar-11 Jun-110%
20%
40%
60%
80%
100%
0
100
200
300
400
500
600
700
67%62% 65% 62% 65% 68% 68%
72% 73% 75% 72% 74% 77%
Proportion # clinics
GROWING PROPORTION OF NEW HIV CARE PATIENTS SCREENED FOR TB
Perc
ent o
f pat
ient
s
Source: ICAP URS June 2011Note: Côte d’Ivoire began reporting in April-June 2008 quarter and South Africa began in July-September 2008 quarter. Data are only from clinics currently supported and reporting. As of March 2010, new HIV care patients excludes patients who knew their TB status at enrollment.
n=22,289 n=26,984 n=30,440 n=33,311 n=34,834 n=38,432 n=43,525
Number of clinics
New HIV care patients
Sep-07 Dec-07 Mar-08 Jun-08 Sep-08 Dec-08 Mar-09 Jun-09 Sep-09 Dec-09 Mar-10 Jun-10 Sep-10 Dec-10 Mar-11 Jun-110%
50%
100%
0
100
200
300
400
500
600
82%88%
83%89% 90% 91% 93% 94%
86% 86%
100%100%
74%84%
76%85%
Proportion # clinics
PROPORTION OF NEW TB PATIENTS WITH UNKNOWN HIV STATUS AT ICAP
SUPPORTED TB CLINICS TESTED FOR HIV OVER TIME
Perc
ent o
f pat
ient
s
n=6,590 n=7,662 n=10,471 n=10,037 n=12,289 n=6,955 n=10,974 n=15,162 TB patients with unknown
HIV status
Source: ICAP URS June 2011.
HIV TESTING AND COUNSELING SERVICES AT ICAP SUPPORTED FACILITIES
Source: ICAP URS June 2011
Num
ber o
f pat
ient
s
Jun-10 Sep-10 Dec-10 Mar-11 Jun-110
100,000
200,000
300,000
400,000
500,000
600,000
293,836
356,053
484,094
528,815 529,479
23,163(8%)
26,285(7%)
33,169(7%)
40,594(8%)
37,422(7%)
Tested and received results HIV+
Jul-08 Oct-08 Jan-09 Apr-09 Jul-09 Oct-09 Jan-10 Apr-10 Jul-10 Oct-10 Jan-11 Apr-110
20
40
60
80
100
120
140
160
180
200
KenyaMozambiqueRwandaTanzaniaOverall
Num
ber o
f clin
icsINCREASING NUMBER OF CARE
AND TREATMENT CLINICS SUBMITTING DATA TO ICAP-NY PATIENT-LEVEL DATA
WAREHOUSE
Source: ICAP Patient-level Data Warehouse June 2011