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Phyllis Kanki Harvard School of Public Health VIIIth Annual Track 1.0 ART Meeting August 2010

Phyllis Kanki Harvard School of Public Health VIIIth Annual Track 1.0 ART Meeting August 2010. HIV Infection. AIDS Cases. Harvard PEPFAR program. 140 Million 36 Million 2 Million. Nigeria. 750,000. Tanzania. 420,000. Botswana. 100,000. Initiated on ART. 2.5. 3.0. 0.0. 0.5.

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Phyllis Kanki Harvard School of Public Health VIIIth Annual Track 1.0 ART Meeting August 2010

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  1. Phyllis Kanki Harvard School of Public Health VIIIth Annual Track 1.0 ART Meeting August 2010

  2. HIV Infection AIDS Cases Harvard PEPFAR program 140 Million 36 Million 2 Million Nigeria 750,000 Tanzania 420,000 Botswana 100,000 Initiated on ART 2.5 3.0 0.0 0.5 1.0 1.5 2.0 Million

  3. HIV Care and Treatment • Clinical master trainers – adult patients only

  4. MDH supported sites in Dar es Salaam (n=50) PUBLIC PRIVATE

  5. Collaborating institutions (MDH): • Muhimbili University of Health & Allied Sciences (MUHAS) • Dar es Salaam City Council • Harvard School of Public Health Total ever enrolled 95,389 (7.6 % children) Ever initiated ARVs 61,433 (8% children) Active on ARVs 45,699 ( 7.6 % children) June 2010

  6. Patient retention • 25.6% of patients ever initiated ARVs are not active • Timely tracking of patients who missed their appointment dates at the clinic by phone calls or physical visits. • Major reasons: • Deaths • Transfers • Refusal to continue • Unknowns • 6035 (95.8%) of missing patients were tracked for the last quarter • 73.4% of those tracked had their vital status ascertained

  7. Patients retention Future Plans to improve tracking • Pairing of counselors/clinicians with a number of patients • Improve understanding, communication and interaction with patients • Create bond between patients and their counsellor/clinicians • Counsellors/clinicians will be able to follow up patients development • Make use of existing NGOs (Pathfinder) who work at community level • Introduce electronic model of tracking, recording and reporting

  8. PMTCT Achievements (133 sites) 7% infection

  9. Public – Private Partnership (PPP) • There is significant contribution from private hospitals • 6.5% of patients from MDH supported sites are treated at private hospitals • Contribute in offloading patients from already overwhelmed public sites • Provide more options for the patients • Contribute towards “access to all strategy”

  10. Botswana’s Masa ART Program • 121,644 patients on ART in the public sector at present (May 2010) • 61.4% female; 6.3% children • 14,995 patients out-sourced from the public to the private sector –(Public-Private-Partnership [PPP]) • 13,394 patients in the private sector (Medical Aid Schemes and the Work-place Programs) • TOTAL: 150,033 (92.8% of need for adults and children)

  11. BHP-PEPFAR ARV Site Support Program Masa Master Trainer/ARV Site Support Program Clinical Laboratory • Monitoring & Evaluation Unit • Linked to: • All ARV sites • Other MOH programs

  12. Clinical Master Trainer Program : ARV Sites Assessed and Supported Masunga Newxade Kalkfontein Palapye Goodhope Werda Middlepit Bokspit Each Mother Site has 3-4 Clinics Mother Sites

  13. Task Sharing • Nurse Prescriber & Dispenser Training to Date - 246 nurses trained in prescribing and dispensing ARVs - 680 nurses trained in ARV dispensing only • Nurse training for Rapid HIV testing and Dried Blood Spot collection in collaboration with PMTCT (38 trained in 4 trainings this quarter)

  14. Laboratory Capacity Building • At start of PEPFAR – 2004: • 2 HIV reference labs performed all CD4 and Viral Load testing for the country • In 2010: • Botswana Lab Master Trainers have trained and supported ALL decentralized labs and private sector labs which run PPP specimens • CD4s - 24 decentralized labs performing 62% • VL – 10 decentralized labs performing 33%

  15. Reasons for Site Support Calls Analysis of 100 calls from BHP Master Trainers Telephone Site Support

  16. New Initiatives • Patient Information Management System –currently developing integrated PIMS II system for PMTCT, HCT, ARV and planning roll-out • Pharmacovigilance • Failure Management Registries • Adolescent –focused programs and training • First data collection for Quality Improvement • Updated analysis of integrated MASA dataset that now has records for over 110,000 patients

  17. Harvard PEPFAR Nigeria • Through Bill & Melinda Gates funding, Harvard has been working with multiple hospitals and prevention programs in Nigeria since 2000 • Started PEPFAR ART activities at 6 tertiary hospitals in 2004 and expanded to a total of 26 sites. • Transitioned 14,100 ART current patients to APIN Ltd

  18. Time-to-failure:Patients identified by both criteria • Median time to virologic failure • 11.1 months • Median time to CD4 failure • 15.3 months • Viral load monitoring identified failure significantly earlier than CD4 criteria (p<0.0001) 11.1 mo. Virologic Failure 15.3 mo. Immunologic Failure % Treatment Success • Patients maintained on virologically non-suppressive ART over a median of 6 months developed an average of 1.96 IAS-mutations with a loss of 1.25 active drugs (Cozzi-Lepri et al. AIDS 2007; 21:721.)

  19. TDF-3TC-NVP (n=813) is Inferior to AZT-3TC-NVP multivariate analysis on virologic failure Failure at 12 months was 16.1% for TDF-3TC-NVP versus 9.5% AZT-3TC-NVP K.Scarsi et al. Vienna, 2010

  20. PMTCT Transmission Rates (n=5320) No statistically significant difference between ART and mono or bi-ART prophylaxis Meloni et al, 2010

  21. -------------------------------------BLANKED OUT----------------------------- Patient Monitoring: Pharmacy Database Adherence Utility • Assess adherence to treatment based on timeliness of drug pick-ups • Use calculation of average percent adherence • Setting up networks so that pharmacists can cross-check prescriptions

  22. Ahmadu Bello University Teaching Hospital Loss to Follow up Rate Lower in ARV Experienced vs. Naïve Patients n= 3001

  23. Comparison of LTFU among Large Treatment Programs in Africa • Assessment of causes of early & late LTFU may elucidate potential interventions

  24. APIN/PEPFAR Sites: 2010 Federal Medical Centre Nguru University of Maiduguri Teaching Hospital State Specialist Hospital Maiduguri Nursing Home Maiduguri Ahmadu Bello University Teaching Hospital University of Ibadan College of Medicine 3 Satellites under UCH Adeoyo Maternity Hospital 43 Oyo DOTS Centres Jos University Teaching Hospital Our Lady of Apostles Hospital Jos 8 Satellite Hospitals, 44 PHCs Federal Medical Centre Makurdi Sacred Heart Catholic Hospital Lantoro University of Nigeria Teaching Hospital 68 Nigerian Military Hospital Creek Hospital Widowcare Abakiliki Ebonyi Nigerian Institute for Medical Research Lagos University Teaching Hospital University of Lagos, College of Medicine Mushin General Hospital PHC-Iru Victoria Island Onikan Women’s Hospital Sites Under APIN Ltd Sites Under Harvard PEPFAR APIN Program Office

  25. Continual training is a critical foundation for optimal prevention, treatment and care programs and sustainability • • Rigorous program evaluation is critical to inform national guidelines and insure optimal care. • • Developing systems for program outcome and impact will facilitate country ownership and sustainability

  26. Botswana R. Marlink P. Burns T. Gaoloathe J. Mukhema N. Ndwapi I. Thior M. Mine C. Bussmann Tanzania W. Fawzie G. Msamanga D. Mtasiwa G. Chalimilla S. Kaaya C. Hawkins S. Ismail M. Mwanyika-Sando Nigeria P. Kanki S.Meloni R. Murphy S. Hosseini J-L Sankalé H.Rawizza B. Chaplin A. Ojesina K. Scarsi K. Hurt B. Taiwo A.Dieng Sarr P. Okonkwo J. Samuels E. Ekong P. Akande T. Jolayemi B. Aluko R. Olaitan S. Sagay S. Ochigbo O. Agbaji O. Idigbe S. Akanmu S. Ogunsola W. Gashau M. Garbati C. Okany I. Adewole R. Nkado D. Olaleye H. Muktar D. Owujekwe J. Abah O. Eberndu N. Nulenga

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