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Two Complementary Approaches to the HIV Care Cascade. ICAP Data Dissemination Meeting Matthew Lamb & Molly McNairy March 13, 2014. Number of selected activities at supported facilities, July-September, 2013. Number of facilities. Source: ICAP Site Census , November 2013 - PowerPoint PPT Presentation
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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?