Beyond StartUp

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Beyond Start-Up

• Reaching for Programmatic Depth and Breadth
• Wafaa El-Sadr

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Number of Persons Receiving ART in Low and Middle
Income Countries, 20022005
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Prevention of Mother to Child Transmission (pMTCT)
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ICAP Roots
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MTCT-Plus Sites

• 13 international sites
• Cote DIvoire
• Cameroon
• Kenya (2)
• Mozambique
• Rwanda
• South Africa(3)
• Thailand
• Uganda(2)
• Zambia

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Women attending ANC clinics
pMTCT programs
Enrollment into pMTCT programs
Enrollment into MTCT-Plus Package of Care
HIV-infected partners and children

• Long-term HIV care services, including
• Family-centered services
• Clinical immunologic monitoring
• Expedited assessment and ART during
• pregnancy
• Prophylaxis for opportunistic infections
• Antiretroviral therapy when indicated
• Early Infant Diagnosis
• Psychological social support services
• Prevention services
• Nutritional counseling support
• Access to family planning services
• Outreach activities

MTCT-Plus
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Formulation of ICAP Approach

• Family-focused approach
• Comprehensive services including ART
• Multidisciplinary teams
• Attention to clinical as well as psychosocial
  issues
• Focus on retention in care and adherence
• Empowerment of patients and linkage to community
  resources

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HIV Treatment Scale Up
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ICAP Programs
Angola Cameroon Cote dIvoire Ethiopia Kenya Leso
tho Mozambique Nigeria Rwanda South Africa
Swaziland Tanzania Thailand Uganda Zambia
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Issues at Start-Up
Medical Records
Peer Programs
Renovation
Data Management
Tools and job aides
Laboratories
Pharmacy
Community mobilization
Training Mentoring
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Number of ICAP-Supported Sites by Country (N310)
Source ICAP Site Census, September 2007
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Enrollment in HIV care and treatment July 2004 -
June 2007(N268,680)
HIV care
Kenya, Nigeria Swaziland Zambia
268,680
Ethiopia
ART
122,408
Lesotho
Rwanda, S. Africa Tanzania
Mozambique
Source ICAP URS, July 2007
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Enrollment of Children in HIV care and treatment
July 2004 - June 2007N28,097
HIV care
28,097
Kenya, Nigeria, Swaziland, Zambia
Ethiopia
Lesotho
ART
11,211
Mozambique
Rwanda, S. Africa, Tanzania
Source ICAP URS, July 2007
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Enrollment in by ART Status, Age, and Sex July
2004 June 2007
Total enrolled in care (n268,680)
Total initiating ART (n122,405)
Source ICAP URS, July 2007
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Initiated and Currently on ART July 2004 - June
2007
Cumulative initiating ART
ART patients retained in care
Source ICAP URS, June 2007
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Reasons for ART discontinuation as of June 2007
Lost to follow-up 56
144 per 1,000 person-years
100 per 1,000 person-years
Dead 39
13 per 1,000 person-years
Stopped ART 5
Does not include patients who transferred out.
Source ICAP URS, July 2007
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Quality of Care Provided to Patients on ART
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Risk of MortalityResource-Limited versus
Resource-Rich Settings
? unadjusted HR ? adjusted HR (adjusted for
cohort, age, sex, baseline CD4, ART-regimen,
disease stage)
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Risk of Death by Baseline CD4 Count
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Average Median CD4 Count at Baseline, 6 and 12
Months after ART initiation
initiating ART
2,299
601
483
2,030
993
1,638
475
9,108
1,178
CD4 data are for subset of patients. Data not
available for Swaziland or Zambia.
Source ICAP URS, July 2007
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Mortality by Baseline CD4 and Adherence
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Ways to Enhance Outcomes in Patients on ART

• Initiation of ART promptly once eligible for ART
• Particular attention to adherence with care
  (visits) with close monitoring
• Promotion of adherence with ART
• Provision of full package of care elements

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What About Patients Enrolled in Care?
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Enrollment in HIV care and treatment July 2004 -
June 2007(N268,680)
HIV care
Kenya, Nigeria Swaziland Zambia
268,680
Ethiopia
ART care
122,408
Lesotho
Rwanda, S. Africa Tanzania
Mozambique
Source ICAP URS, July 2007
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Enrollment in HIV Care by CountryJuly 2004 -
June 2007 (n268,680)
Source ICAP URS, July 2007
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Proportion Initiated ART By Country(Total
enrolled in care 268,680)
268,680
35,593
26,827
9,184
24,716
4,618
14, 786
85,440
36,737
18,854
ART status breakdown not available for Swaziland
Source ICAP URS, July 2007
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Natural History of Untreated HIV-1 Infection
Asymptomatic Period
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Risk of Opportunistic Infections by CD4 Cell
Count
Holmes et al, J AIDS, 2006
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CD4 Cell Count Decline by CD4 Stratum
Adjusted for age and sex
Holmes et al, J AIDS, 2006
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Focus on Patients in HIV Care

• Attention to retention of patients and adherence
  with visits
• Clinical and immunologic monitoring
• Provision of components of care package
• Support of disclosure and reaching HIV-infected
  partners, children and household members
• Attention to prevention of transmission

Family-Focused Care Comprehensive
Services Multidisciplinary Teams Supportive
Services Retention and Adherence
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Conclusions

• For both patients enrolled in care or on ART,
  need to focus on
• Package of care
• Quality of care
• Emphasis on patients enrolled in care not
  eligible for ART likely to have substantial
  impact on individual and community
• Clinical mentoring centered on teams of providers
  is key to achieving optimal programmatic impact

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