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Project HEART- Overview
Stephen LEE. MDElizabeth Glaser Pediatric AIDS Foundation
presenting for the Project HEART Team
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
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
Project HEART supports activities in five countries
Côte d’Ivoire
Mozambique
South Africa
Tanzania
Zambia
Côte d’Ivoire
Zambia
Tanzania
South Africa
Mozambique
Countries Involved in Project HEART
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
Côte d’Ivoire EGPAF-Supported Sites
Number of active ART sites in June 2007 = 77
Zambia EGPAF-Supported Sites
Number of active ART sites in June 2007 = 40
Tanzania EGPAF-Supported Sites
Number of active ART sites in June 2007 =38
South Africa EGPAF-Supported Sites
Number of active ART sites in June 2007 = 11
Mozambique EGPAF-Supported Sites
Number of active ART sites in June 2007 = 17
Project HEART: Patient Enrollment1
269,649
226,227
189,820
167,401
134,426117,996
96,37079,706
41,88531,337
15,039
142,249
20,84936,712
45,56157,882 68,536
86,69697,870
117,203
0
50,000
100,000
150,000
200,000
250,000
300,000
Q1-05 Q2-05 Q3-05 Q4-05 Q1-06 Q2-06 Q3-06 Q4-06 Q1-07 Q2-07
Cumulative Number on HIV Care
Cumulative Number on ART
30
36
56
73
92
94
119
144
163
183
1. CUMULATIVE data by June 30, 2007
2. Boxed numbers indicate the number of active sites each quarter
1. Number of patients living with HIV, ever enrolled in long-term clinical care and support programs.2. Of those enrolled, number of patients started on ARV therapy.
CUMULATIVE data from March 1, 2004 through June 30, 2007
Project HEARTCumulative Patient Enrollment
Country
HIV Palliative Care1 Antiretroviral Treatment2
Children Adults Total 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 660 (6%) 11,000 11,660 178 (5%) 3,631 3,809
Total 23,091 (9%) 246,558 269,649 11,525 (8%) 130,724 142,249
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 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
Total 13,984 (9% ) 151,098 165,082 9,406 (9%) 99,821 109,227
1. Number of HIV-positive patients who received care anytime during April 1st-June 30th 2007.
2. Number of patients on Treatment on June 30th 2007.
One-Year Patients Retention on ART 07/01/06 – 06/30/07
CountryPts on ART as of 7-01-06
Pts Enrolled on ART, 7-01-06 to 6-30-07
Pts No Longer on ART 7-01-06 to 6-30-07
Pts on ART as of 6-30-07
ART Retention
Rate 7-01-06 to 6-30-07
Number of sites 7-01-06
Number of sites 6-30-07
(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% 28 40
Total 56,494 72,607 23,194 105,907 82.% 84 166
Total Attrition
25.3%
19.7%
9.1%
26.1%
33.1%
18.0%14.6% 14.5%
25.7%
33.8%
0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
30.0%
35.0%
40.0%
Zambia South Africa Mozambique
Children (0-14 years) Adults (15 years or more)
% of patients who ever started ART at a facility who were not on ART at the end of June 2007
Reasons for Attrition
Country Stopped Transferred out
Died Lost to FU Unknown
Zambia 4% 36% 28% 16% 16%
Côte d’Ivoire 2% 8% 17% 52% 21%
South Africa 7% 55% 21% 9% 8%
Tanzania 3% 30% 37% 29% 2%
Mozambique 7% 13% 21% 30% 29%
Total 4% 18% 14% 9% 9%
Change in Median CD4 Count 6-Month Cohort
12795
149129
271
141
261285
0
50
100
150
200
250
300
350
Cote d'Ivoire South Africa Tanzania Zambia
CD
4 co
un
t ce
ll/m
m3
CD4 at baseline CD4 at 6 months
Change in Median CD4 Count 12-Month Cohort
107 94 98120
300
238
148
319
0
50
100
150
200
250
300
350
400
Cote d'Ivoire South Africa Tanzania Zambia
CD
4 co
un
t ce
ll/m
m3
CD4 at baseline CD4 count at 12 months
Outcomes after 1 year of ART:Côte d’Ivoire
• Retrospective cohort of 10,211 patients on ART at 19 sites in Côte d’Ivoire (2004-2007)
• 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
Pediatric Outcomes after 1 year of ART: South Africa
• Retrospective Cohort of 151 children on ART in McCord Hospital, South Africa (2003-2005)
• Median age: 6 years (Range: 0.3-15)• Median follow-up time: 8 months (3.5-13.5)• Treatment: ARV/CTX• Outcome at 12 month
– Median gain in CD4%: 16% (IQR 9.6-20.3)– 12 month survival: 91% (IQR 84.8-94.6)
MCCord Hospital: BMC Pediatrics 2007, 7:13
Number of EGPAF PMTCT sites,Project HEART countries (2004-2007)
0
50
100
150
200
250
300
350
400
450
Ju
n-0
4
Au
g-0
4
Oct-
04
Dec-0
4
Feb
-05
Ap
r-05
Ju
n-0
5
Au
g-0
5
Oct-
05
Dec-0
5
Feb
-06
Ap
r-06
Ju
n-0
6
Au
g-0
6
Oct-
06
Dec-0
6
Feb
-07
Ap
r-07
Ju
n-0
7
Cote d'Ivoire
Mozambique
South Africa
Tanzania
Zambia
EGPAF PMTCT sites: Project HEART countries(Uptake %, counseling, testing, results; HIV+ among tested)
0
200000
400000
600000
800000
1000000
1200000
Eligiblewomen
Counseled Tested Results HIV+
Cumulative July 05 - June 06 July 06 - June 07
105%
101%
108%
81%
77%
84%
97%
98%
98%
16%
12%12%
EGPAF PMTCT sites: Project HEART countries(HIV+, uptake %, Women and Infant ARV)
0
20000
40000
60000
80000
100000
120000
140000
160000
HIV+ Women ARV Infant ARV
Cumulative July 05 - June 06 July 06 - June 07
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
Infrastructure, Systems Support Technical Assistance
• Infrastructure– 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
Country
HCW Trained in ARTHCW Trained in
non-ART
Physicians Nurses Other Total Total
Zambia 331 3781 1839 5951 571
Côte d'Ivoire 334 19 83 436 179
South Africa 380 190 436 1006 859
Tanzania 293 280 89 662 21
Mozambique* NA NA 92 92 85
Total 1338 4270 2539 8147 1715
Trained Health Care Workers
Cumulative from October 1, 2005 - June 30, 2007
*Mozambique training data includes data from July 1, 2006-June 30, 2007
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
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
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
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
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
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
Acknowledgements
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.
Elizabeth Glaser Pediatric AIDS Foundation
NRTI-Induced Lactic AcidosisSouth Africa
• Cohort of 891 patients on ART at McCord Hospital, South Africa (2004-2005)
• 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; 96:722-724