Post on 31-Mar-2015
From HIV diagnosis to treatment: From HIV diagnosis to treatment: Implementing a referral system to Implementing a referral system to
monitor access to ART in Kisesa Wardmonitor access to ART in Kisesa Ward
Ray Nsigaye, Doris Mbata, Alison Wringe, Benjamin Clark, Maria Roura, Basia Zaba and Mark Urassa
TAZAMA / NACP seminar TAZAMA / NACP seminar
Dar-es-Salaam, September 19Dar-es-Salaam, September 19thth 2008 2008
OverviewOverview
BackgroundBackground Design of the referral systemDesign of the referral system Data collection methodsData collection methods FindingsFindings Policy recommendationsPolicy recommendations
BackgroundBackground
CTCVCT
How effective is the VCT site as a “gateway” to ART?
OR
N=?
N=?
What % of diagnosed VCT clients register at ART sites?
UNDERGO V CT
AGREE TO UNDERGO REFERRAL
ELIGIBLE FOR ART
INITIATE ART
"KIS ES A COM M UNITY"
ATTEND ART CLINIC
ART ACCESS PROCESS
Access to ARTAccess to ART
HIV negative
HIV positive – no ART need
HIV positive - needs ART
UNDERGO V CT
AGREE TO UNDERGO REFERRAL
ELIGIBLE FOR ART
INITIATE ART
"KIS ES A COM M UNITY"
ATTEND ART CLINIC
ART ACCESS PROCESS
Access to ARTAccess to ART
HIV negative
HIV positive – no ART need
HIV positive - needs ART
UNDERGO V CT
AGREE TO UNDERGO REFERRAL
ELIGIBLE FOR ART
INITIATE ART
"KIS ES A COM M UNITY"
ATTEND ART CLINIC
ART ACCESS PROCESS
Access to ARTAccess to ART
HIV negative
HIV positive – no ART need
HIV positive - needs ART
Referral system objectivesReferral system objectives
To link diagnosed, HIV-positive persons with a local ART clinic
To document referral rates following VCT
To document referral uptake at ART clinic
To link referral data to CTC clinic data to monitor treatment initiation and continuation rates
Methods - surveysMethods - surveys
Every 3 years, HIV serological and sexual behaviour surveys are conducted in Kisesa ward in temporary village-based clinics.
VCT services were available on-site in the 2004 and 2007 surveys.
VCT attendance data can be linked to demographic and serosurvey data - including separate HIV testing conducted for research purposes, without disclosure of results.
Methods – HIV servicesMethods – HIV services
Since Jan 2005:Since Jan 2005:Permanent VCT clinic in Kisesa health centre
Free ART available from BMC
Referrals to BMC for all HIV+ Two-part referral forms, with unique matching Two-part referral forms, with unique matching
numbers numbers Transport allowance Transport allowance Escort from a local HBC groupEscort from a local HBC group
DEMOGRAPHIC DATASET
VCT DATASET
REFERRAL FORMS
CTC PATIENT RECORDS
VCT NUMBERVCT NUMBER
CTC PATIENT IDENTIFIERCTC PATIENT IDENTIFIER
SURVEY IDENTIFIERSURVEY IDENTIFIER
Delays between referral & CTC registration
0%
20%
40%
60%
80%
100%
Sero survey Health centre
0 days 1-7 days 8-31 days 1-9 mths No registration
n=165 n=341
0%
20%
40%
60%
80%
100%
men w omen
n=214 n=363
Delays between referral & CTC registration
0%
20%
40%
60%
80%
100%
Mar05-Aug05
Sep05-Feb06
Mar06-Aug06
Sep06-Feb07
Mar07-Aug07
Sep07-Feb08
0 days 1-7 days 8-31 days 1-9 mths No registration
n=35n=53n=33 n=26 n=40 n=54
Treatment pyramid Jan 05-Dec 07Treatment pyramid Jan 05-Dec 07
CTC Utilization
200 150 100 50 0 50 100 150 200
01/01/2005
01/03/2005
01/05/2005
01/07/2005
01/09/2005
01/11/2005
01/01/2006
01/03/2006
01/05/2006
01/07/2006
01/09/2006
01/11/2006
01/01/2007
01/03/2007
01/05/2007
01/07/2007
01/09/2007
01/11/2007
Mon
ths
Male FemalePopulation
Female Ever EnrolledFemale Currently EnrolledFemale Ever On ARTFemale Currently On ARTMale Ever EnrolledMale Currently EnrolledMale Ever On ARTMale Currently On ART
CD4 change after ART initiation
y = 0.33x + 37.26
-200
0
200
400
600
800
1000
0 200 400 600 800 1000
Days Since Started ART
Chan
ge in
CD
4 Co
unt
Results: ART accessResults: ART access
17% (135/810) of HIV-infected persons had completed VCT
7% (56/810) had been referred to the ART clinic
6% (48/810) had registered for ART clinic services within 3 months of their referral.
Among those who registered at the ART clinic, 60% (29/48) had initiated ART by March 2007.
Results: unmet needResults: unmet need
0%
20%
40%
60%
80%
100%
Male Female Remote Roadside <30 30+
SEX RESIDENCE AGE
Pe
rce
nta
ge
of
HIV
+ s
ero
pa
rtic
ipa
nts
Registered at CTC
Referred not registered
VCT, no referral
No VCT
n=468n=342 n=462n=347n=430n=379
ConclusionsConclusions
Referral system: Facilitate access to ART for HIV + Assess effectiveness of VCT as an entry to
ART Describe gender patterns in referral rates
and uptake Monitor delays in referral uptake in relation
to availability of “support” services Trace no-shows at the ART clinic
Policy recommendationsPolicy recommendations
• Implement referral systems in sites where rates of referral uptake may be low: PMTCT PITC
Ensure that potential barriers to referral uptake are addressed: Transportation Escort HBC
Next stepsNext steps
Continue to monitor access to ART (>3 years) Describe trends in gender, residence and age
patterns throughout the process of ART access. Compare referral rates from different VCT
services Compare referral uptake at BMC and at the new
ART clinic in Kisesa Monitor referrals HBC-VCT and VCT-HBC