from hiv testing to treatment: operations research to improve arv treatment programs
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From HIV Testing to Treatment: Operations Research to Improve ARV Treatment Programs. Treatment Acceleration Program Meeting November 30, 2006 Mark Micek, MD, MPH Health Alliance International University of Washington. ARV expansion in Mozambique. ~1.7 million HIV-infected - PowerPoint PPT PresentationTRANSCRIPT
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From HIV Testing to Treatment:
Operations Research to Improve ARV Treatment Programs
Treatment Acceleration Program MeetingNovember 30, 2006
Mark Micek, MD, MPHHealth Alliance International
University of Washington
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ARV expansion in Mozambique
• ~1.7 million HIV-infected
• ~270,000 need ARVs
• ~30,000 on ARVs (8/06)– 11% of those in need
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HAI in Mozambique
• Works exclusively with public sector
• Provincial/district/facility level support– Sofala and Manica Provinces (27% and 19% HIV+)– Expansion of testing and ARV care sites
• 23 ARV care sites with ~6,000 on ARVs
– OR
• National level support– Maputo
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GuroGuro TambaraTambara
ChembaChemba
MaringueMaringueMacossaMacossa
SussundengaSussundenga
MachazeMachaze
MachangaMachanga
MuanzaMuanza
CheringomaCheringoma
ChibabavaChibabava
HF Providing HAART (new)
17 (13)
PLWHA Registered (%) 36,270 (9)
Eligible in HAART (%) 5,250 (9)
Children <15 y in HAART (% of those in HAART)
420 (8)
HIV Treatment Expansion Plan
2006
2003 2004
2005 2006
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GuroGuro TambaraTambara
ChembaChemba
MaringueMaringueMacossaMacossa
SussundengaSussundenga
MachazeMachaze
MachangaMachanga
MuanzaMuanza
CheringomaCheringoma
ChibabavaChibabava
HF Providing HAART (new) 53 (7)
PLWHA Registered (%) 100,490 (25)
Eligible in HAART (%) 23,903 (40)
Children <15 y in HAART (% of those in HAART)
3,585 (15)
HIV Treatment Expansion Plan
2008
2003 2004
2005 2006
2007 2008
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Testing is first step to entering HIV care system
HIV testing centers VCT
Home-based Care
Pregnant
Day Hospital Clinical evaluation (CD4)
Start HAART in
eligible patients
Adherence to ARV
Treatment Adherence to
Care
Youth
Community
TB patients
Ill/Hospitalized Hospital
Youth VCT
pMTCT
STEP 1 HIV Testing
STEP 2 Arrival to
Day Hospital
STEP 3 CD4
Testing
STEP 4 Start
HAART
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Why patients don’t start HAART: where are patients lost?
Monthly flow through the HIV care system in Beira and Chimoio, Mozambique, Jun 04 - Sept 05
HIV+
Undergo CD4 testing (78%)
Enroll at HIV clinic (59%)
Eligible for HAART (48%)
Start HAART (46%)
0
100
200
300
400
500
600
700
Ave
rag
e p
atie
nts
per
mo
nth
Step 1
Step 2
Step 3
Step 4
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Specific problems with targeted HIV testing
• Targeted HIV testing = aimed at a specific group– High-risk (TB, hospitalized)– Special services available (pMTCT)
• Problems noted with testing treatment flow– pMTCT– TB patients
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How can we improve the efficiency of targeted HIV testing?
• Changing counseling strategies– Opt-in Opt-out
• Operational questions:– Will opt-out ↑ HIV testing?– Will opt-out ↑ HIV treatment?– Will opt-out ↑ HIV prevention? (another talk)
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Problem 1: Loss of pregnant women
• Year 2005: Beira (2 sites) and Chimoio (3 sites)– 52% of pregnant women tested for HIV
(opt-in)– 28% of HIV+ arrived at an HIV clinic
• 68% VCT (difference p<.001)
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Possible solution: change the testing strategy at pMTCT sites
2005 vs. 2Q 2006: ↑ testing by 535/mo (p<.001)↑ HIV+ by 96/mo (p<.001)↑ arrival to HIV clinic by 14/mo (p=.07)
Number of pregnant women testing for HIV and arriving at an HIV clinic
0
200
400
600
800
1000
1200
1400
Q1 2005 Q2 2005 Q3 2005 Q4 2005 Q1 2006 Q2 2006
Quarter
Nu
mb
er
of
pre
gn
an
t w
om
en
# Tested for HIV
# HIV-positive
# Arriving at HIVclinic
% of pregnant women testing for HIV and arriving at an HIV clinic
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
Q1 2005 Q2 2005 Q3 2005 Q4 2005 Q1 2006 Q2 2006
Quarter
% o
f p
reg
na
nt
wo
me
n
% Tested for HIV
% Arriving at HIVclinic
Strategy ∆Strategy ∆
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Situation not unique
• UNICEF 2003: 11 national pMTCT programs– 49% of HIV+ women received ARV for pMTCT
• Kenya (Malonza, AIDS, 2003)– 1249/1282 accepted test (97%)– Rapid tests associated with higher proportion receiving
results (96% vs. 73%, p<.001)– No difference in receiving ARV for pMTCT (19% vs. 11%,
p=.2)
• Malawi (Manzi, Trop Med Int Health, 2005)– 96% accepted test– 45% of HIV+ and 34% of babies received SD-NVP– Infant to follow-up 81% by 6-months
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Need to improve referral
• Improve counseling?– Activists recruited to follow mothers (planned)
• Reduce stigma?– Community mobilization– Partner testing
• Decentralize care services?– pMTCT sites with on-site HIV clinic: ~70% referred– CD4 testing (started in pMTCT sites 7/06)– Clinical services (i.e. HAART)
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Problem 2: High loss of TB patients
• 2004-2005, TB sites in Beira city– Few TB patients tested for HIV at local VCT (opt-in)
• New TB patients enrolled ~ 250/mo• TB patients tested for HIV ~20/mo
– ~8% of estimated TB-HIV patients enrolled into care at HIV clinic*
• Operational questions:– Will opt-out ↑ HIV testing?– Will opt-out ↑ HIV treatment?
* Micek, MA, Integrating TB and HIV Care in Mozambique: Lessons from an HIV Clinic in Beira. CORE TB/HIV Case Study, The CORE Group, Washington DC, September 2004.
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Possible solution: Change testing & care for patients in TB treatment
Old system
TB patient treated at TB center
Referred to VCT center for HIV testing
Referred to HIV clinic for:
HIV counselingTreatment of OIs
CTX proph.HAART
If HIV+
Continue at TB clinic for: TB treatment
New system
TB patient treated at TB center
“Opt-out” HIV testing at TB centerRotating VCT counselors
TB nurses
Referred to HIV clinic for:
HIV counselingTreatment of OIs
HAART
If HIV+
Continue at TB clinic for:
HIV counselingTB treatmentCTX proph.
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Initial results
• Implemented in 6 TB facilities in Beira city, Sep 05
• Indicators collected using routine data systems
• First 7mo (Sep 05 – Mar 06)– 1,290 patients tested for HIV
• ~60% of all TB patients – 916 (71%) HIV-positive
• Additional ~20% already knew status
– 834 (91%) received CTX proph.– 504 (55%) registered at HIV clinic– 128 (14%) started HAART
• 25% of those arriving to the HIV clinic
• High acceptance from patients, TB staff and VCT counselors
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How to improve referral?
• Better counseling?
• Streamline treatment of TB patients at HIV clinic?
• Decentralize more HIV services to TB sites?
• CD4 counts• HAART
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OR Center in Beira, Mozambique• Collaboration between MOH,
UW, HAI
• Support OR activities in central Mozambique– Agenda development
• Involve policy personnel– Technical support
• Protocol development• Study management• Analysis of results
– Training– IRB review (future)
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Other examples of OR
• Improve follow-up at HIV care facilities• Evaluate decentralization of HIV services to
primary health care– Follow-up– Quality of care
• Improve HAART adherence– mDOT– Community-based treatment supporters
• Support human resource development– Expand mid-level provider responsibilities– Plan health worker allocation– Retain health care workers
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Thank you