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