Two Complementary Approaches to the HIV Care Cascade

ICAP Data Dissemination MeetingMatthew Lamb & Molly McNairy

March 13, 2014

Total dis-tinct facili-

ties

ART Care PMTCT HIV testing for TB pa-

tients

TB screen-ing for HIV

patients

Lab Early Infant Diagnosis

HIV Test-ing and

Counseling

PwP HRH0

500

1000

1500

2000

2500

3000

3500

3062

1150 1153

2516

895

1279

519

48

1495

291

662

NUMBER OF SELECTED ACTIVITIES AT SUPPORTED FACILITIES, JULY-SEPTEMBER, 2013

Num

ber o

f fac

ilitie

s

Source: ICAP Site Census, November 2013Note: Some facilities offer more than one activity.

Sep-04

Dec-04

Mar-05

Jun-05

Sep-05

Dec-05

Mar-06

Jun-06

Sep-06

Dec-06

Mar-07

Jun-07

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-11

Sep-11

Dec-11

Mar-12

Jun-12

Sep-12

Dec-12

Mar-13

Jun-13

Sep-13

0

200,000

400,000

600,000

800,000

1,000,000

1,200,000

1,400,000

1,600,000

1,800,000

2,000,000

0

200

400

600

800

1000

1200

1400

1600

HIV care ART Clinics ever reporting

CUMULATIVE ENROLLMENT IN HIV CARE AND TREATMENT, BY QUARTER

Source: ICAP URS November 2013.Note: Includes adults and children. Data are from all clinics ever supported.

Num

ber o

f pat

ient

s Number of clinics

971,893 initiated ART

1,787,682 enrolled in care

1,474 clinics

As of September 2013:

Sep-04

Dec-04

Mar-05

Jun-05

Sep-05

Dec-05

Mar-06

Jun-06

Sep-06

Dec-06

Mar-07

Jun-07

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-11

Sep-11

Dec-11

Mar-12

Jun-12

Sep-12

Dec-12

Mar-13

Jun-13

Sep-13

0

20,000

40,000

60,000

80,000

100,000

120,000

140,000

160,000

180,000

0

200

400

600

800

1000

1200

1400

1600

HIV care ART Clinics ever reporting

CUMULATIVE PEDIATRIC ENROLLMENT IN HIV CARE AND TREATMENT, BY QUARTER

Source: ICAP URS November 2013.Note: Data are from clinics ever supported.

Num

ber o

f pat

ient

s Number of clinics

86,010 initiated ART

159,734 enrolled in care

1,474 clinics

As of September 2013:

Overall n=4902

Kenya n=1423

Mozambique n=359

Ethiopia n=1801

Tanzania n=1168

Cote d'Ivoire n=151

0

100

200

300

400

148

185 180

138116

98

241

287

331

228

185170

266

326343

249

209

166

Baseline 6-month 12-month

MEDIAN CD4 COUNT AT BASELINE, 6 AND 12 MONTHS AFTER ART INITIATION, BY COUNTRY,

JULY-SEPTEMBER, 2013

CD4

Cell C

ount

(cel

ls/ul

)

Source: ICAP URS November 2013Notes: This reflects cumulative cohort data for patients followed 12 months. Baseline CD4 count is an average of 6 and 12 month cohort baseline data. Data are only from clinics currently supported and reporting.

Jun-07

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-11

Sep-11

Dec-11

Mar-12

Jun-12

Sep-12

Dec-12

Mar-13

Jun-13

Sep-13

0

500,000

1,000,000

1,500,000

2,000,000

2,500,000

3,000,000

3,500,000

4,000,000

4,500,000

5,000,000

0

500

1000

1500

2000

2500

3000

3500

ANC visit HIV tested Clinics ever reporting

Number of pregnant women attending ANC and receiving HIV testing, April 2007 – September 2013

Source: ICAP URS November 2013.Notes: Data from clinics ever supported.

Num

ber o

f wom

enN

umber of clinics

4,067,373 HIV tested

4,660,865 attending ANC

3,282 clinics

As of September 2013:

TYPE OF ART REGIMEN FOR PMTCT, BY QUARTERPe

rcen

t of w

omen

Source: ICAP URS November 2013Notes: Multi-drug regimens include AZT/sd-NVP, AZT/3TC tail postpartum, HAART at 34 weeks.Data are only from clinics currently supported and reporting.

Dec-09 Mar-10 Jun-10 Sep-10 Dec-10 Mar-11 Jun-11 Sep-11 Dec-11 Mar-12 Jun-12 Sep-12 Dec-12 Mar-13 Jun-13 Sep-130%

50%

100%

62% 59%67%

75% 81% 83%75% 74% 71% 67% 61% 64% 60% 63%

54%

32%

6% 7%6%

7%

12% 5%10% 9% 10%

8%9%

11%11%

13%20%

41%

31% 34% 27%18%

6% 12% 10% 11% 13% 8% 4% 2% 4% 3% 6% 5%

0.05718041410.05744622920.0606645230.16240553140.26449616570.2173344430.25445873080.20781771750.19920079920.2177606178

Multi-drug regimens Newly initiating ART Already on ART SD-NVP

Mar-07

Jun-07

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-11

Sep-11

Dec-11

Mar-12

Jun-12

Sep-12

Dec-12

Mar-13

Jun-13

Sep-13

0

100,000

200,000

300,000

400,000

500,000

600,000

700,000

800,000

900,000

1,000,000

0

200

New care enrollment TB screening at enrollment

Number of new HIV patients screened for TB, April 2007-September 2013

Source: ICAP URS November 2013.Notes: Data are from clinics that ever reported.

Num

ber o

f pat

ient

s Num

ber of clinics

568,917 TB screened

949,693 enrolled in care

1,566 clinics

As of September 2013:

Mar-07

Jun-07

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-11

Sep-11

Dec-11

Mar-12

Jun-12

Sep-12

Dec-12

Mar-13

Jun-13

Sep-13

0

1,000,000

2,000,000

3,000,000

4,000,000

5,000,000

6,000,000

7,000,000

8,000,000

9,000,000

10,000,000

11,000,000

-

500

1,000

1,500

2,000

Tested and received results HIV+ Facilities ever reporting

Number of people tested for HIV, as of September 2013

Source: ICAP URS November 2013.Notes: Data are only from clinics currently supported and reporting.

Num

ber o

f peo

ple

Num

ber of clinics

476,472 HIV+

9,536,893 HIV tested

1,936 facilities

As of September 2013

VCT* n=52611

Other** n=65108

Inpatient n=35119

Outpatient n=454103

Outreach n=2219

0%

10%

20%

30%

40%

50%

60%

13%10%

3% 2% 1%

20%24%

51%

28% 28%

HIV+ Enrolled in HIV care

Source: ICAP URS November 2013 Notes: *Most data from VCT clinics comes from Ethiopia, which may decrease the overall prevalence found in VCT clinics. **Other includes: laboratory; family planning, well-baby, STI, and TB clinics; casualty/trauma; palliative care/hospice; customer care, cervical cancer screening; HIV care / ART (family testing); blood donation center; and other points of service.

PROPORTION OF PATIENTS TESTED WHO WERE HIV+ AND ENROLLED IN CARE, BY

POINT OF SERVICE, JULY-SEPTEMBER 2013

Prop

ortio

n of

pat

ient

s

Number of tests conducted, by type of test, as of September 30, 2013

Source: ICAP URS November 2013.Notes: Data are from labs ever supported.

Num

ber o

f tes

tsN

umber of laboratories

1,334,098 CD4 count

2,011,452 HIV rapid tests

As of September 2013:

454,868 CD4 %

494,055 AFB

606 laboratories

Jun-10 Sep-10 Dec-10 Mar-11 Jun-11 Sep-11 Dec-11 Mar-12 Jun-12 Sep-12 Dec-12 Mar-13 Jun-13 Sep-130

500,000

1,000,000

1,500,000

2,000,000

2,500,000

0

100

200

300

400

500

600

700

800

900

HIV rapid tests CD4 count CD4% AFB Clinical labs ever reporting

Upcoming SI Webinars

March 27: Care and treatment and lab PFacTS

Other: URS, logic models, DHIS and surveillance

Overview• Background– “HIV continuum of care”– How the continuum of care is typically measured

• Measure the continuum using ICAP data 1. Traditional HIV Care Cascade 2. Alternative HIV Care Cascade

• Use of both cascade approaches to inform a comprehensive assessment of patient outcomes and program performance

ART EligibleLink

McNairy, El-Sadr AIDS 2012

HIV Continuum of Care

• A theoretical framework outlining essentials components of HIV care and treatment

• Failure in any one step results in overall system failure: morbidity, mortality and HIV transmission

2005 2006 2007 2008 2009 2010 2011 2012 2013

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

1.8

2Pa

tient

s in

MIL

LIO

NS

Why do we care about the continuum?

1 million

1.8 million

HIV Care

ARTICAP Care and Treatment Programs (2005-2013)

16

Background: Traditional Cascade

The traditional HIV care cascade is a tool to map the HIV continuum of care using a series of steps

– Each step is conditional on the previous step – Focus on treatment (ART) with common endpoint of viral load suppression

Literature: Cascades, Cascades, Cascades

Gardner et al, CID 2011, CDC MMWR 2012, Kaygamba et al, Plos One 2012, Mugglin et al, Trop Med 2012

18

Background-2

• The traditional cascade provides incredibly useful information.

• However, incomplete insight as it does not account for:– Outcomes for patients not on ART (Pre-ART)– The multiplicity of reasons for losses between steps– Timeframes for achievement of each step of the cascade

• HIV programs expanding to include Pre-ART patients and there is a need to evolve the traditional cascade to include outcomes of these patients

19

Purpose of Study• To measure the traditional HIV care cascade among adult

HIV-infected patients enrolled in ICAP-supported HIV care and treatment facilities in sub-Saharan Africa

• To develop an alternative cascade approach to:– Account for outcomes of all patients (Pre-ART+ART)– Identify reasons for losses across each step of cascade– Measure outcomes over time (i.e., 3, 6, 12 months)

20

• Routinely collected data on 390,603 adults (>15 years) enrolled in HIV care at 217 ICAP-supported care and treatment sites in 4 countries from 2005-2011

• Participants in The Identifying Optimal Models for HIV Care in Africa Study

Kenya:85 clinics101,938 patients

Mozambique:34 clinics201,503 patients

Rwanda:41 clinics32,105 patients

Tanzania:57 clinics55,057 patients

Study Population and Setting

21

MethodsSteps in this study’s cascade were adapted for available data

Traditional Cascade Available Study Data

HIV infected Not available

HIV diagnosed Not available

Linked to care • Enrolled in care

Retained in care • Assessed for ART eligibility (CD4/WHO Stage)

On ART • ART eligible using national guidelines 2005-2011• Initiated ART

Suppressed viral load • ART retention at 12 months

22

Methods-2Population• Pre-ART: any patient not on ART (ART-ineligible, unknown eligibility, ART-eligible

not initiated)• ART: any patient with documented initiation of ART

Outcomes• Loss to follow-up (LTF)

ART: not attending a care visit > 6 months Pre-ART: not attending care visit > 12 months

• Death and transfers based on data in patient records• Retention: Percent known to be alive, not LTF, and attending clinic

Methods• Kaplan-Meier to estimate cumulative incidence of retention after ART initiation

Results

24

-

100,000

200,000

300,000

400,000 390,603

167,523

117,525 91,211

345,839

70%

Assessment for ART

eligibility

Traditional Cascade

ART Retention at 12 months

Num

ber o

f adu

lt HI

V pa

tient

s

N = 390,603 patients at 217 clinics in Kenya, Mozambique, Tanzania, and Rwanda

48%

70%78%

89% 23%

25

-

100,000

200,000

300,000

400,000 390,603

167,523

117,525 91,211

345,839

70%

Assessment for ART

eligibility

Traditional Cascade Findings

ART Retention at 12 months

Num

ber o

f adu

lt HI

V pa

tient

s

N = 390,603 patients at 217 clinics in Kenya, Mozambique, Tanzania, and Rwanda

Outcomes of these patients not traditionally included

-

100,000

200,000

300,000

400,000 390,603

167,523

117,525 91,211

345,839(89%)

(43%)

Who is lost: after enrollment?

(30%)(23%)

CD4/WHO stage within 12 months

Num

ber o

f adu

lt HI

V pa

tient

s

89% LTF 3% Death (recorded) 4% Transfer 3% Pre-ART retention

Assessment for ART

eligibility

ART Retention at 12 months

-

100,000

200,000

300,000

400,000 390,603

167,523

117,525 91,211

345,839(89%)

(43%)

Who is lost: after assessment for ART eligibility?

(30%)(23%)

CD4/WHO stage within 12 months

Num

ber o

f adu

lt HI

V pa

tient

s

48% LTF 2% Death 26% ART initiation 8% Transfer16% Pre-ART retention

Assessment for ART

eligibility

ART Retention at 12 months

28

-

100,000

200,000

300,000

400,000 390,603

167,523

117,525 91,211

345,839

70%

Assessment for ART

eligibility

Traditional Cascade Findings

ART Retention at 12 months

Num

ber o

f adu

lt HI

V pa

tient

s

N = 390,603 patients at 217 clinics in Kenya, Mozambique, Tanzania, and Rwanda

48%70%

78%

89%

Traditional Cascade By Country

0%

20%

40%

60%

80%

100%

Overall Rwanda Tanzania Kenya Mozambique

All countries end up at similar

endpoint(22%-26%)

ART retention at 12 months

Traditional Cascade

What it can tell us?• % of patients achieving each

step • % of patients lost across each

step• Which step is the “weakest”

link in the cascade• Use of common desired

cascade endpoint (VLS, ART retention) which is essential for optimized patient outcomes

What is missing?• Outcomes of all patients

(Pre-ART, transfers)• Reasons for losses across

each step • Timeline

Alternative Cascade Approach• All patients followed across time

– Each step begins not from previous step but from enrollment – Outcomes of the entire cohort are described

• Outcomes are categorized

Optimal

Suboptimal

Poor

Retained, Transferred

Retained but did not receive optimal care, missing data

LTF, Death

Alternative Cascade%

of a

dult

HIV

patie

nts Retained ART-ineligible

Initiated ART

Retained on ART

Transfer out

Optimal Outcomes

Time (months) since HIV care enrollment

Enrollment 3 months 6 months 12 months0%

20%

40%

60%

80%

100%390,603

58%51% 49%

Alternative Cascade%

of a

dult

HIV

patie

nts

Time (months) since HIV care enrollment

Retained indeterminate eligibility

Retained ART-eligible but not initiated

Suboptimal Outcomes

Enrollment 3 months 6 months 12 months0%

20%

40%

60%

80%

100%390,603

Alternative Cascade%

of a

dult

HIV

patie

nts

Time (months) since HIV care enrollment

Death (Pre-ART)

LTF (Pre-ART)

Poor Outcomes

LTF (ART)

Death (ART)

0 months 3 months 6 months 12 months0%

20%

40%

60%

80%

100%390,603

Enrollment

0 months 3 months 6 months 12 months0%

20%

40%

60%

80%

100%

Alternative Cascade Summary%

of a

dult

HIV

patie

nts

Time (months) since HIV care enrollment

100%

58% 51% 49%

7%

44%

12%

37%

22%

20%

56% of patients retained

Poor

Suboptimal

Optimal

Enrollment

Alternative Cascade: Mozambique%

of a

dult

HIV

patie

nts

Time (months) since HIV care enrollment

Poor

Suboptimal

Optimal

Enrollment 3 months 6 months 12 months0%

20%

40%

60%

80%

100%

100%

53%44% 41%

25%

12%8%

23%

44%52%

201,503 patients(52% of all patients)

34 Clinics (16% of all clinics)

Alternative Cascade: Tanzania%

of a

dult

HIV

patie

nts

Time (months) since HIV care enrollment

Enrollment 3 months 6 months 12 months0%

20%

40%

60%

80%

100%

100%

61%54% 51%

20%

12%8%

19%

35%41%

Poor

Suboptimal

Optimal

55,057 patients(14% of all patients)

57 Clinics (26% of all clinics)

Alternative Cascade: Kenya%

of a

dult

HIV

patie

nts

Time (months) since HIV care enrollment

Enrollment 3 months 6 months 12 months0%

20%

40%

60%

80%

100%

100%

58% 54% 52%

21%

13%8%

21%33%

40% Poor

Suboptimal

Optimal

101,938 patients(26% of all patients)

85 Clinics (39% of all clinics)

Alternative Cascade: Rwanda%

of a

dult

HIV

patie

nts

Time (months) since HIV care enrollment

Enrollment 3 months 6 months 12 months0%

20%

40%

60%

80%

100%

100%87% 84% 83%

8%5% 3%

5% 10% 14%

Poor

Suboptimal

Optimal

32,105 patients(8% of all patients)

41 Clinics (19% of all clinics)

40

SummaryCascade Approach Cascade Endpoint Strengths

• 23% (91,211) achieve ART retention at 12 months

• Measures drop-off between steps

• Common desired endpoint for ART patients

• 49% (190,122) have optimal outcomes at 12 months

• 56% (218,738) retained in care

• Follows all patients• Stratifies poor

outcomes into pre-ART and ART

• Includes time

Traditional

Alternative

Summary by CountryCascade Approach Cascade Endpoint Conclusion

• Kenya: 24%• Mozambique: 22%• Rwanda: 26%• Tanzania: 26%

• Similar outcomes across countries

• Kenya: 52%• Mozambique: 41%• Rwanda: 83%• Tanzania: 51%

• Very different outcomes across countries

Traditional

Alternative

ConclusionsComplementary approaches• Traditional cascade – focuses on treatment with overarching programmatic

goal of continued successful retention and adherence– Identifies modifiable bottlenecks in achieving that goal• ART eligibility ART initiation

• Alternative cascade– Focuses on outcomes of all patients (Pre-ART and ART)– Pre-ART losses are the majority of poor outcomes– Shows large heterogeneity between country programs

Conclusions-2• Neither study cascade includes the desired start point(s)– HIV infection– HIV diagnosis– Linkage to HIV care

• The ultimate value of HIV care cascades is to inform the design and implementation of multicomponent interventions that achieve desired patient outcomes and population impact

Applying to ICAP…next steps

• Utility for – routine program monitoring and evaluation?– assessing impact of interventions targeting key

steps in the continuum of HIV care?– Other applications?

Questions?