Using m -health strategies to improve laboratory data management in PMTCT programs

1. Using m-health strategies to improve laboratory data management in PMTCT programs m-health satellite Washington, July 23, 2012

2. Large numbers of HIV-infected children continue to get infected despite increasing access to PMTCT Financing overview: Malawi is expecting a funding gap in the near term, but significant worsening after 2013, unless additional funding is secured • Access to PMTCT services has expanded markedly in recent years • UNAIDS estimates that ~350,000 pediatric HIV infections have been prevented since 1995 • But…at best, we are preventing only 20-25% of new infections annually • In 2010, there were an estimated 390,000 new pediatric infections • More than 1,000 infants are newly infected each day • In the absence of treatment, mortality in these infants is very high – approaching 50% by age 2 Source: UA report 2011, Newell et al. Lancet 2005

3. We need to improve performance and strive for “eMTCT”, but we also must do a better job of treating the children already living with HIV Financing overview: Malawi is expecting a funding gap in the near term, but significant worsening after 2013, unless additional funding is secured 51% Adults Receiving ART Children Receiving ART 42% Coverage % - Children Coverage % - Adults 23% 21% 6.2M 4.9M 3.8M 2.8M 1.9M 1.3M 0.5M 0.4M 0.3M 0.2M 0.1M 0.1M 2005 2006 2007 2008 2009 2010 Adapted from: UA report 2011

4. On the continuum of care for HIV positive mothers and children, infant diagnosis is essential for infant treatment and program monitoring Financing overview: Malawi is expecting a funding gap in the near term, but significant worsening after 2013, unless additional funding is secured Opt A/B ART HIV Ab test CD4 for ART eligibility Infant Diagnosis ART monitoring in mothers and children Infant diagnosis is essential to monitor progress towards eMTCTand identify infected infants

5. But, infant diagnosis requires virologic testing using DNA-PCR Financing overview: Malawi is expecting a funding gap in the near term, but significant worsening after 2013, unless additional funding is secured • All HIV exposed infants have maternal HIV antibodies so infant diagnosis requires virologic testing • DNA PCR identifies the DNA of the virus in cells but requires many steps including extraction, amplification and detection of HIV DNA • Use of innovative blood collection methods such as Dried Blood Spots (DBS) has enabled many national programs to offer this test by using sample transport to link peripheral sites to central labs

6. Using DBS and sample transport, in many countries, EID testing has scaled up rapidly in recent years Financing overview: Malawi is expecting a funding gap in the near term, but significant worsening after 2013, unless additional funding is secured Uganda example Number of sites providing PMTCT 507 646 947 Number of Sites providing EID 145 (29%) 285 (44%) 550 (58%)

7. But scale up of EID has not translated to scale up of infant treatment due to high rates of LTFU – especially between testing and results return Financing overview: Malawi is expecting a funding gap in the near term, but significant worsening after 2013, unless additional funding is secured Infant Retention Cascade at 3 Regional Referral Hospitals in Uganda Sept 2007 – Feb 2009 39% of positive infants never received results 35% of positive infants receiving results were never enrolled into care 42% of positive infants in care & treatment were lost Source: CHAI/MOH Uganda 2011

8. Postnatal PMTCT visits are linked to EPI at 6 and 10 weeks. If the turn around time is too long, EID results are not there when mothers return Caregiver returns for results DBS drawn for PCR Birth 6 wks 10 wks Batch sent to lab Results Dispatched Sample Tested 14 days 5 days 6 days 18 days Kangemi Health Center – Nairobi Total TAT 39 days 6 days 5 days

9. GSM Printers were used to reduce turnaround time from availability of result to delivery to clinic Caregiver returns for results DBS drawn for PCR  Birth 6 wks 10 wks Batch sent to lab Sample Tested 14 days 5 days 6 days 6 days 5 days

10. What’s next after the SMS printers?? An “EID-ecosystem” to leverage the SMS network and build a real time national database of test results A Public-Private partnership between HP, NASCOP and Safaricomresulted in the creation of a real time, online database to track EID nationally Safaricom supports the auto SMS function Auto SMS to clinic confirming receipt and providing batch number Sample information entered into data terminal EID sample received at lab Information instantly enters NASCOP’s data “cloud” This wireless “ecosystem” enables >2,000 facilities to have access to all data & test results over SMS and web in real time AND allows program staff to review national, regional and site level performance Sample processed and result entered into data terminal HP provided & supports servers Paper result dispatched to clinic Auto SMS sent to clinic with result

11. EID data can be accessed through a web interface http://www.nascop.org/eid

12. EID data can be accessed through a web interface http://www.nascop.org/eid

13. What lessons have we learned, what challenges remain? • PPPs work! The support of CHAI, HP and Safaricom has created a highly effective system • Building trust with partners was critical. Although it took a while to bring partners on board and overcome concerns of data sharing, the benefits of being able to access and view real time information is apparent to all • With transparency comes accountability. Lab performance is closely tracked and problems can be addressed very quickly • Clinics and providers are empowered by seeing their performance and having access to this technology • The national EID data system helps us track progress better than ever before, but EID is a clinical service not only a programme monitoring tool. When a test is positive it is essential to link that child to treatment and this remains a challenge in many settings