FHI’s Global ART Program:Today's snapshot and tomorrow's vision

10 August 2010

Kwasi Torpey, MD, PhD, MPHRegional Senior Technical Advisor, FHI

8th Annual Track 1.0 ART Meeting

Part 1: Today’s SnapshotOverview of FHI’s Global ART Program

• Provision of ART in 14 countries – across Asia, Africa and the Caribbean

• 322,586 patients currently on ART as of March 2010; of those:– 102,164 (31.7%) are in Zambia– 101,700 (31.5%) are in Nigeria– 23,245 (7.2%) are less than 15 yrs. old

• 30,091 patients were newly enrolled on ART from Jan 2010 – March 2010– 2,143 (7.1%) are less than 15 yrs. old

Early Infant Diagnosis (EID): Dried Blood Spot DNA-PCR

• Currently being implemented in 6 African countries: Zambia, Kenya, Nigeria, Mozambique, Tanzania & Rwanda

• Over 45,000 children tested through EID– 27,274 in Zambia alone

• Systems for early delivery of results and integration into under 5 clinics

– sms printers

– Web2sms for results pick up

Early Infant Diagnosis (EID): Dried Blood Spot DNA-PCR (2)

• Linking DBS results to determine effectiveness of PMTCT intervention

• Assessing the role of non drug factors eg. Disclosure, infant feeding, home vs facility to optimize effectiveness and efficiency in the light of limited resources

Part 2: Tomorrow’s VisionThe Future of ART programming

• Health Systems Strengthening platform• Integration of HIV services beyond Sexual,

Reproductive Health & TB. One target community, many diseases!

• Long-term tracking of ART patients• Sustainability

Overview of FHI’s TB/HIV Services

• Screening for TB and/or provision of TB treatment for HIV+ patients in 15 countries

• Integration of TB-HIV services

• As of March 2010:– 149,808 HIV+ patients were screened for TB in HIV

setting– 5,699 HIV+ patients in HIV care/treatment started TB

treatment

FHI Kenya’s CVD/HIV Integration Pilot

1. Assess CVD risk factors among:

– HIV Counseling & Testing (CT) clients

– HIV+ patients in care– HIV+ patients on ART

2. Provide behavioral and biomedical interventions (on site and/or through referral)

3. Document and disseminate lessons learned

Rationale for integration

• CVD complications in HIV patients• Burden of CVD and HIV among developing countries;

In Kenya:– HIV prevalence is 7.1%, with 1.5 Million PLWHA, and

390,000 on HAART– NCD contributes to 50% morbidity and 32% mortality

(Kenya MOH, 2007)

• Opportunity to combine lessons learned in CVD &HIV• Improve efficiency of health care delivery

Risk of high blood pressure according to HIV status (among CT clients)

81%

68% 70%

19%

32% 30%

0%

20%

40%

60%

80%

100%

HIV- (n=1,079) HIV+ (n=4,307) Total (N=5,386)

HIV Serostatus

Blo

od

Pre

ss

ure

(R

an

ge

)

Normal High P-value 0.003

Other findings

• Elevated blood sugar levels in 2nd line patients

• Increased lipids in second line patients

• High blood pressure related to duration of treatment

Strategies for tracking ART Patients

• Adherence support workers– Home visits and patient tracking

• SMS reminders– Web2sms for adherence and loss to follow up– Consent forms

• HMIS– Smartcare - Zambia

• 93,233 current ART patients (6,844 >15 yrs. – 7.3%)– Lafiya Management Information System (LAMIS) -

Nigeria

Lafiya Management Information System (LAMIS) - Nigeria

• 60,361 patients being tracked

• 14 facilities• Data included:

– Patient history– ART status and drug

regimen– TB and DOTS status– Clinical stage– Lab tests & results– Facility and lab setup– Specimen storage– Drug Inventory

Attaining operational sustainability

Technical Sustainability

Programmatic Sustainability

Social Sustainability

Financial Sustainability

Operational Sustainability

OVERALL SUSTAINABILITY

DistrictOverall score (%) by quarter

Months before graduationQ3 2008 Q4 2008 Q1 2009 Q2 2009 Q3 2009

District 1 91.5 86 90 90 G 3yr 10mo

District 2 87 92.2 G G G 2yr 11mo

District 3 87 92.9 G G G 3yr

District 4 97 G G G G 3yr 1mo

District 5 84 92.4 G G G 3yr 10mo

District 6 78 85.4 92.6 G G 3yr 10mo

District 7 87 87.8 93.2 G G 3yr 3mo

District 8 89.6 84.2 94.2 G G 3yr 4mo

District 9 83 84.4 94 94 G 4yr

District 10 82.5 83.2 91.4 91.4 G 2yr 8mo

G = Graduated Average 3yr 4mo

Challenges for Sustainability

• Limited pre-service & in-service exposure to QI concepts

• Absence of strong QI system within MoH

• Use of financial incentives to drive QI & graduation activities

• High HCW turnover rate

• Financial sustainability