International Center for AIDS Care and Treatment Programs

1
Orientation to data collection processes and
inaugural quarterly discussion of latest data on
ICAP programs MER April 25 2007 ICAP quarterly
data meeting
2
Objectives

• Review and discuss the process of data
  collection, cleaning, analysis and dissemination
  in NY and in-country
• Share latest data on ICAP supported programs
  across 14 countries
• Discuss how data are or can be used for program
  improvement
• Discuss format of future ICAP quarterly data
  meetings

3
Outline

• Unified Reporting System (URS)
• Site Census
• Program and Facility Characteristics Tracking
  System (P-FaCTS)
• Care and treatment data
• PMTCT() data
• TB/HIV data
• Patient-level data
• Open discussion

4
ICAP/CU-supported countries
5
ICAP supports an estimated 694 programmatic
activities at 260 facilities in 14 countries (2.7
activities per site)

• Need to capture standard donor and ICAP
  indicators on the scale and quality of
  ICAP-supported programs on a quarterly basis.
• Care treatment 166 indicators (203 of 222
  sites reporting as of 4/07)
• PMTCT 37 indicators (105/115 sites reporting as
  of 04/07)
• TB/HIV 22 indicators (not yet started, expected
  from 141 sites)
• Testing counseling, infant diagnosis, adherence
  support in the works
• Programs are expanding, diversity of programming
  is expanding
• Need for more indicators?!

6
Unified Reporting System (URS)

• What Central reporting system that utilizes a
  web-based application for capturing and
  disseminating data on multiple ICAP-supported
  activities and programs
• Purpose To streamline, standardize, and increase
  the efficiency and utilization of routinely
  collected data by any ICAP staff member

7
URS structure
Data collection
Data processing
Data entry
Outputs
QA
Web components
Datasets
Data checks cleaning
Donor/MOH reports
Canned/ ad hoc reports
Maps
Detailed analyses
8
Site Census module

• What Real-time inventory of all planned,
  current, and closed ICAP sites. Supported
  activities, funding source(s) and their targets
  are also captured
• Purpose To have one up to date master list of
  sites, activities and targets that all ICAP staff
  can refer to for planning and evaluation

9
Number of ICAPsupported sites by activity, March
2007
Source ICAP Site Census, March 2007
10
Number of ICAP-supported sites by country, March
2007 (n274)
Source ICAP Site Census, March 2007
11
Program and Facility Characteristics Tracking
System (P-FaCTS) module

• What Collects program and facility information
  on ICAP-supported care and treatment programs
  semi-annually
• Purpose To describe the scope, diversity, and
  comprehensiveness of ICAP-supported care and
  treatment programs, and evaluate multi-level
  factors that influence program performance and
  patient-level outcomes

12
P-FaCTS nomenclature and examples of information
collected
Context (e.g., Washington Heights, NYC) Urban/rural, adult and antenatal HIV prevalence, TB incidence
Site (i.e., CU Presbyterian Hosp) Services e.g., pMTCT, labor and delivery, TB, VCT Characteristics Type, catchment population, number of beds
Facility (i.e., an HIV clinic within the site) Physical plant e.g., exam rooms, area of facility Programmatic e.g., patient support groups, nutritional support, adherence support Staffing of physicians, nurses, counselors, pharmacists Laboratory CD4, HIV RNA, infant diagnosis, liver function test
13
Location and type of ICAP-supported care and
treatment facilities (n162)
Source P-FaCTS January 2007
14
Availability and comprehensiveness of on-site
services at ICAP-supported care and treatment
facilities (n162)
Source P-FaCTS January 2007
15
Availability and comprehensiveness of patient
support services at ICAP-supported care and
treatment facilities (n162)
Source P-FaCTS January 2007
16
Availability and comprehensiveness of on-site
laboratory services at ICAP-supported care and
treatment facilities (n162)
Source P-FaCTS January 2007
17
Number of providers per 1000 patients on ART at
ICAP-supported care and treatment facilities
(n162))
Source P-FaCTS January 2007
18
P-FaCTS summary

• Care and treatment programs vary in
  comprehensiveness of services offered
• Activities and components of ICAP-supported care
  and treatment programs are dynamic, therefore
  necessary to conduct routine surveys
• PFaCTS data can be used in conjunction with
  program data for program planning and evaluation

19
Care and treatment
20
Number of ICAP-supported care and treatment sites
by country, March 2007 (n222)
Source ICAP Site Census, March 2007
21
Care and treatment aggregate indicators received
onquarterly basis by facility (currently 209/222
in 10 countries)

• Pre-ART and ART care enrollment by age, sex and
  pregnancy status
• CD4 count for ART patients (baseline, 6 and 12
  months)
• ART regimens by age
• ART discontinuation and reasons
• Number of trainings on ART and palliative care

22
Care and treatment indicator collection and
submission
CDC-Atlanta
MER CT Lead
MER Liaison
MER Liaison
Program Review
Data queries
Data queries
Manual data checks
MER Data Analyst

On-line reporting module (URS)
Automated data checks
Automated data checks
ME Officer
USG
USG
ME Officer
Site B
Site A
Site A
Site B
ME Clinical staff
ME Clinical staff
23
Uses of care and treatment data

• In-country USG reporting
• Track 1.0 reporting (Atlanta)
• Dissemination of data for program evaluation and
  planning
• Summary tables and graphs
• By country and time period
• Slide set for presentations
• Important trends
• In-depth analyses
• Abstracts from Implementer and IAS meeting

24
Example of quarterly summary data table country
over time
25
Example of facility line list for each country
26
Number of ICAP-supported care and treatment sites
reporting by country, July 2004 December 2006
(Total number of sites reporting 165)
27
Cumulative enrollment in HIV care (pre-ART and
ART) ART care at ICAP-supported sites, July
2004 - December 2006
HIV care (pre-ART and ART)
Nigeria, Swaziland, Zambia added
ART Care
Ethiopia added
Lesotho added
Kenya Rwanda So. Africa Tanzania
Mozambique added
28
Cumulative pediatric enrollment in HIV care
(pre-ART and ART) ART care at ICAP-supported
sites, July 2004 - December 2006
HIV care (pre-ART and ART)
Nigeria, Swaziland, Zambia added
ART Care
Ethiopia added
Lesotho added
Kenya Rwanda So. Africa Tanzania
Mozambique added
29
Cumulative enrollment in ICAP-supported sites by
ART status and country, July 2004 - December 2006
Total in care (n185,903)
ART care (n87,746)
30
Cumulative enrollment in pre-ART vs. ART care in
ICAP-supported care and treatment sites by
country as of December 2006 (Total in care
185,903)
N23,908
N13,056
N21,616
N4,417
N26,532
N22,746
N59,079
N3,118
N11,431
Swaziland data not available
31
Cumulative enrollment in HIV care (pre-ART and
ART) by age, sex and country at ICAP-supported
sites as of December 2006 (Total in care
185,903)
Swaziland data not available
32
Cumulative enrollment on ART by age, sex and
country at ICAP-supported sites as of December
2006 (Total on ART 87,746)
33
Mean number of patients enrolled in
ICAP-supported care and treatment facilities
34
Mean number of patients enrolled in
ICAP-supported care and treatment facilities (and
country variability)
35
ART eligibility and initiation for patients
receiving care at ICAP-supported care and
treatment sites, October to December 2006
(Total received care during quarter 127,943)
36
ART regimens in adults and children at
ICAP-supported sites October-December 2006
Adults 15 ()
Ethiopia Kenya Mozambique Nigeria Rwanda South Africa Tanzania Overall
N9,643 N5,405 N11,146 N769 N7,493 N7,617 N4,766 N46,839
d4T-3TC-NVP 53 78 77 46 46 9 80 56
d4T-3TC-EFV 20 8 10 1 9 86 4 24
ZDV-3TC-NVP 19 3 3 49 29 1 10 11
ZDV-3TC-EFV 8 1 4 4 13 2 6 6
2nd line regimen 0 3 6 0 2 1 0 2
Unknown 0 5 0 0 2 0 0 1
Children lt15 ()
Ethiopia Kenya Mozambique Nigeria Rwanda South Africa Tanzania Overall
N514 N460 N616 N10 N754 N981 N319 N3,644
d4T-3TC-NVP 19 58 50 100 48 26 5 29
d4T-3TC-EFV 6 17 4 0 9 62 3 22
ZDV-3TC-NVP 69 12 43 0 26 2 72 30
ZDV-3TC-EFV 4 2 1 0 16 15 8 9
Other 0 0 0 0 0 14 0 4
2nd line regimen 1 2 3 0 1 18 12 7
Unknown 0 10 0 0 1 0 0 2
In South Africa, d4T-3TC-LPV/r is also
prescribed as a first-line regimen
37
Average median CD4 count (cells/µL) at baseline
and 6 and 12 months after ART initiation by
country at ICAP-supported sites as of December
2006
CD4 data not available for all ART patients.
Data not available for Nigeria, Swaziland, and
Zambia.
38
Reasons for ART discontinuation at ICAP-supported
sites as of December 2006
39
Reasons for ART discontinuation by country at
ICAP-supported sites as of December 2006
N1241
N1989
N2,701
N1,103
N3,119
N634
N4
N319
Transfers not considered discontinuers
40
Comparing results and targets
41
ART patients in more comprehensive programs may
have better follow-up care
Median74
Support activities include peer-educator program,
outreach program nutritional support, adherence
support
Median44
1 or 2 activities
3 or 4 activities
Source Quarterly report data and PFaCTS, January
2007
42
PMTCT/PMTCT-plus
43
Number of ICAP/CU-supported pMTCT() sites, March
2007 (n115)
Source ICAP Site Census, March 2007
44
PMTCT()Currently 115 facilities in 5 countries

• Developed list of 39 indicators (counseling and
  testing in ANC, prophylaxis to mother and infant,
  maternity, follow-up of exposed infant)
• 95 of 115 sites in 5 countries reported 4 key
  indicators (Oct-Dec 2006)
• Next round will include all 39 indicators
• Expect close collaboration and communication btwn
  ME and PMTCT program staff

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46
ICAP model

• Family focused care
• PMTCT is the entry point for HIV-infected women
  to access care and ART if eligible
• ANC testing is the first step of the process
• But need to go beyond that to ensure that
• women are accessing care and treatment and
• HIV-exposed infants receive follow-up

47
Women tested in ANC and received results95
ICAP-supported PMTCT sites, October-December, 2006
48
Women receiving SD-NVP in ANC 95 ICAP-supported
PMTCT sites, October-December, 2006
49
Provision of services to pregnant women in
ICAP-supported PMTCT programs in Mozambique,
Nigeria, Rwanda, Tanzania (February,
2005-September, 2006)
50
Enrollment and outcomes from 20 UTAP supported
PMTCT sites in Mozambique, 2006
51
Provision of services to pregnant women in
ICAP-supported PMTCT programs in 4 countries
(Mozambique, Nigeria, Rwanda, Tanzania) (February,
2005-September, 2006)
52
Early Infant Diagnosis4 sites in Tanzania, Oct
1, 2006-March 21, 2007
53
Limitations of aggregate data

• Cannot evaluate whether pregnant women are
  enrolled in care and treatment when eligible
• Difficult to measure efficacy of PMTCT program
  without linking mothers PMTCT and infant
  prophylaxis and infant outcome

54
MTCT-Plus pMTCT and pregnancy/infant
monitoring Example Following the index
pregnancy
24 not recently pregnant
196 HIV-inf women enrolled Dec 05, all
eventually initiated ART for tx
6 pregnancy ended prior to term
Monitoring for new/subsequent pregnancies at HIV
clinical care visits
13 unk pregnancy outcome (for investigation)
172 enrolled AP/ recently PP
Adult women
153 live births
linked by moms ID
129 mom recd pMTCT/ or initated ART tx
Infant HIV testing diagnosis Breastfeeding
monitoring Clinical monitoring CTX prophylaxis
Infants
14 children not enrolled in M (for
investigation)
139 children enrolled in M
10 moms pMTCT unk
Data source 2 MTCT-Plus sites (1 in Kenya, 1 in
South Africa)
55
Targeted Evaluations

• Addresses Why
• Helps identify barriers and facilitating factors
• Provides details

56
Reasons for not taking SD-NVPamong women who
received it

57
Newborn brought to health facility for SD-NVP
among women who delivered at home
If newborn brought to facility, timing of visit
58
Conclusions

• Excellent uptake of counseling and testing in ANC
  
• MZ 81
• TZ 86
• RW 99
• Within countries, seroprevalence in ANC
  consistent over time
• TZ 83 of exposed children receiving PCR 85
  started CTX
• Linking maternal and infant outcomes
• Linking mother to Care and Treatment

59
TB/HIV
60
Number of ICAP/CU-supported TB/HIV sites (n141),
March 2007
Source ICAP Site Census, March 2007
61
TB/HIV

• Developed list of 20 indicators (TB screening,
  diagnosis, and treatment HIV counseling and
  testing at TB clinics and enrolment into HIV care
  and treatment)
• Integrated 4 SOC indicators
• 114 sites in 6 countries expected to report
  Jan-March 07 data by end of May 07
• Expect close collaboration and communication
  between ME and TB/HIV program staff

62
TB Screening among HIV-positive patients
receiving care treatment in ICAP-supported TB
Model Centers in Mozambique Rwanda
Mozambique (August-November, 2006)
Rwanda (January-December, 2006)
63
HIV testing among TB patients in ICAP-supported
sites in Rwanda and South Africa
South Africa (September-December, 2006)
Rwanda (January-December, 2006)
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Conclusions

• Good implementation of TB screening in Rwanda and
  Mozambique (SOC target is over 90)
• HIV counseling and testing at TB clinics is
  efficient way to identify patients
• Hard to capture linkages data TB clinic ? HIV
  clinic HIV clinic ? TB clinic

65
Patient-level data on care and treatment
66
What is meant by patient-level data?

• Information collected for each patient at every
  clinic visit
• Clinical data
• Laboratory results
• Medication
• Patient disposition/status

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Purpose of collecting patient-level data with
electronic databases

• Consistent with MOH priorities
• Improve quality of care (e.g. tracked missed
  visits, identify patients who have missed visits)
• Automate routine reporting (e.g. reduce burden of
  MOH and other routine reporting)
• Compare patient outcomes across sites to evaluate
  models of care

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Patient-level data
Mozambique N11,557 n () 5 facilities Ethiopia N7197 N () 6 facilities Rwanda N7672 n () 7 facilities 6 additional countries N5844 (adults only) n () 6 facilities Total N32,270 n () 24 facilites
MTCT-plus supported sites PEPFAR supported 389 (3) 11,168 (97) 0 (0) 7197 (100) 321 (4) 7351 (96) 5844 (100) 0 (0) 6554 (20) 25,716 (80)
Female Male Missing 6782 (59) 4677 (40) 98 (lt1) 4111 957) 3084 (43) 2 (lt1) 4985 (65) 2460 (32) 227 (3) 4874 (83) 963 (16) 7 (lt1) 19,048 (59) 10,735 (33) 2487 (8)
ART care Non-ART care 3876 (34) 7681 (66) 1185 (16) 6012 (84) 3177 (41) 4495 (59) 2163 (37) 3681 (63) 10,401 (32) 21,869 (68)
Age at enrolment 0-14 y yrs 15-25 yrs 26-35 yrs 36-45 yrs gt45 yrs Missing 141 (1) 2069 (18) 4621 (40) 2976 (26) 1750 (15) 0 (0) 716 (10) 1281 (18) 3041 (42) 1589 (22) 570 (8) 0 (0) 585 (8) 1016 (13) 2747 (36) 2156 (28) 1092 (14) 76 (lt1) n/a 1860 (32) 3190 (55) 704 (12) 77 (1) 13 (lt1) 1446 (4) 6226 (19) 13,599 (42) 7425 (23) 3489 (11) 85 (lt1)
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Patient-level data
Mozambique N11,557 n () 5 facilities Ethiopia N7197 N () 6 facilities Rwanda N7672 n () 7 facilities 6 additional countries N5844 (adults only) n () 6 facilities Total N32,270 n () 24 facilities
WHO stage at enrolment Stage 1 Stage 2 Stage 3 Stage 4 Missing 1140 (10) 1105 (10) 2465 (21) 451 (4) 6396 (55) 164 (2) 314 (4) 697 (10) 174 (2) 5848 (81) 2042 (27) 1852 (24) 2008 (26) 197 (3) 1573 (20) 3560 (61) 1207 (21) 931 (16) 140 (2) 6 (lt1) 6906 (21) 4478 (14) 6101 (19) 962 (3) 13823 (43)
CD4 count at enrolment in care Median (range) 199 (1,1812) n5282 Missing 328 (0,1996) n6501 345 (1,1845) n5120 297 (0,1996) N16,903
Point of entry into care pMTCT VCT In-patient Out-patient Other Missing 445 (4) 5286 (46) 530 (5) 2910 (25) 1559 (13) 827 (7) 33 (lt1) 3399 (47) 1 (lt1) 4 (lt1) 756 (11) 3004 (42) 1585 (21) 4710 (61) 400 (5) 158 (2) 396 (5) 423 (6) 5844 (100) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 13,395 (42) 931 (3) 7907 (24) 2711 (8) 3072 (10) 4254 (13)
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MTCT-Plus patient-level data Example 1
Plot of CD4 cell count measurements by time on
ART for a cohort of 1321 adult patients from 13
sites initiating ART
Data as of August 2005
72
MTCT-Plus patient-level data Example 2
Plot of CD4 cell count measurements, stratified
by baseline CD4 count group, by time on ART for a
cohort of 1836 pediatric patients from 13 sites
initiating ART
Data as of August 2005
73
MTCT-Plus patient-level data Example 3 Program
losses in a cohort of gt2000 adult patients from
13 sites who initiated ART,
over time since ART initiation
K-M by Gender
K-M Overall
Log-rank test (p0.22)
K-M by Gender
voluntary program withdrawals, deaths, LTF
Data as of August 2005
74
Future patient-level data analyses

• Measure outcomes (e.g. survival, change in CD4
  count) of patients in more ICAP-supported care
  and treatment programs
• Identify facility and program-level
  characteristics that independently influence
  patient outcomes

75
Current assessment of indicator reporting for
ICAP-supported activities by country
Country Site Care Treatment PMTCT TBHIV CounselingTesting Lab
Cameroon 1          
Cote dIvoire 2          
Ethiopia 35          
Kenya 29          
Lesotho 5          
Mozambique 40          
Nigeria 42          
Rwanda 37          
South Africa 41          
Swaziland 13          
Tanzania 24          
Thailand 1          
Uganda 2          
Zambia 2          
14 274 222 115 141 103 108

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Key messages and recommendations
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Discussion

• Implications for country work plans
• Ideas for future format for quarterly data
  meeting
• How better we can feedback data to country
  offices?
• Currently indicator tables, graphs, line listings
• Dataset of indicators for local analysis
• PFaCTS summary tables, linelistings, and datasets
• Future
• Online canned and ad hoc reports from URS
• Combine info from all URS modules
• Online mapping capabilities from URS
• Country profiles (annual, semiannual)?
• In-country quarterly data reviews?
• Other formats/fora?

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Where to find MER outputs

• P/MER Public
• Eventually on web