Phyllis Kanki
Harvard School of Public Health
VIIIth Annual Track 1.0 ART Meeting
August 2010
Harvard PEPFAR program
Nigeria
750,000
140 Million
Tanzania
420,000
36 Million
HIV Infection
AIDS Cases
Initiated on ART
Botswana
100,000
2 Million
0.0
0.5
1.0
Million
1.5
2.0
2.5
3.0
HIV Care and Treatment
Botswana
Nigeria
Tanzania
Total
Persons ever enrolled in
HIV Care
18,975*
118,688
95,389
233,052
Persons ever initiated on
ART
13,578*
76,166
61,433
151,177
154
26
50
230
---
61
133
194
Number of ART Facilities
Number of PMTCT
Facilities
•Clinical master trainers – adult patients only
MDH supported sites
in Dar es Salaam (n=50)
PUBLIC
PRIVATE
Collaborating institutions (MDH):
Muhimbili University of Health
& Allied Sciences (MUHAS)
Dar es Salaam City Council
Harvard School of Public
Health
Ever initiated ARVs
61,433
(8% children)
Total ever enrolled
95,389
(7.6 % children)
Active on ARVs
45,699
( 7.6 % children)
June 2010
Patient retention
 25.6% of patients ever initiated ARVs are not active
 Timely tracking of patients who missed their appointment dates
at the clinic by phone calls or physical visits.
 Major reasons:
 Deaths
 Transfers
 Refusal to continue
 Unknowns
 6035 (95.8%) of missing patients were tracked for the last quarter
 73.4% of those tracked had their vital status ascertained
Patients retention
Future Plans to improve tracking
 Pairing of counselors/clinicians with a number of patients
 Improve understanding, communication and interaction
with patients
 Create bond between patients and their
counsellor/clinicians
 Counsellors/clinicians will be able to follow up patients
development
 Make use of existing NGOs (Pathfinder) who work at
community level
 Introduce electronic model of tracking, recording and
reporting
PMTCT Achievements (133 sites)
OctDec 08
JanMar 09
AprJun 09
JulySept
09
OctDec 09
JanMar 10
AprJun10
Total tested
19,335
21,116
20,741
21,808
25,937
28,166 24,298
Overall
prophylaxis
26.7%
33.7%
51.5%
69.6%
56.6%
61.2%
80.5%
HIV exposed
infants
registered
-
518
549
356
310
1357
1389
Confirmed +ve
-
7
2
1
1
94
98
Cotrimoxazole
Prophylaxis
-
371
13
184
205
179
229
EID Sites
-
13
13
14
42
58
65
7% infection
Public – Private Partnership
(PPP)
 There is significant contribution from private
hospitals
• 6.5% of patients from MDH supported sites are
treated at private hospitals
• Contribute in offloading patients from already
overwhelmed public sites
• Provide more options for the patients
• Contribute towards “access to all strategy”
Botswana’s Masa
ART Program
 121,644 patients on ART in the public sector at
present (May 2010)
 61.4% female; 6.3% children
 14,995 patients out-sourced from the public to the
private sector –(Public-Private-Partnership [PPP])
 13,394 patients in the private sector (Medical Aid
Schemes and the Work-place Programs)
 TOTAL: 150,033
(92.8% of need for adults and children)
BHP-PEPFAR ARV
Site Support Program
Masa
Master Trainer/ARV
Site Support Program
Clinical
Laboratory
Monitoring & Evaluation Unit
Linked to:
• All ARV sites
• Other MOH programs
Clinical Master Trainer Program : ARV
Sites Assessed and Supported
Masunga
Newxade
Kalkfontein
Palapye
Werda
Bokspit
Goodhope
Middlepit
Mother Sites
Each Mother Site has 3-4 Clinics
Task Sharing
 Nurse Prescriber & Dispenser Training to Date
- 246 nurses trained in prescribing and dispensing
ARVs
- 680 nurses trained in ARV dispensing only
 Nurse training for Rapid HIV testing and Dried Blood
Spot collection in collaboration with PMTCT (38
trained in 4 trainings this quarter)
Laboratory
Capacity Building
 At start of PEPFAR – 2004:
 2 HIV reference labs performed all CD4 and Viral
Load testing for the country
 In 2010:
 Botswana Lab Master Trainers have trained and
supported ALL decentralized labs and private
sector labs which run PPP specimens
 CD4s - 24 decentralized labs performing 62%
 VL – 10 decentralized labs performing 33%
Reasons for Site Support Calls
Analysis of 100 calls from
BHP Master Trainers Telephone Site Support
New Initiatives
 Patient Information Management System –currently
developing integrated PIMS II system for PMTCT, HCT,
ARV and planning roll-out
 Pharmacovigilance
 Failure Management Registries
 Adolescent –focused programs and training
 First data collection for Quality Improvement
 Updated analysis of integrated MASA dataset that now
has records for over 110,000 patients
Harvard PEPFAR Nigeria
•Through Bill & Melinda Gates funding, Harvard has
been working with multiple hospitals and prevention
programs in Nigeria since 2000
•Started PEPFAR ART activities at 6 tertiary hospitals in
2004 and expanded to a total of 26 sites.
•Transitioned 14,100 ART current patients to APIN Ltd
Year 1
Year 2
Year 3
Year 4
Year 5
Year 6
18,518
36,504
59,051
75,512
113,567
449
1,132
2,167
3,060
5121
12,165
23,108
38,050
55,793
72,906
97
485
1,284
1,951
3,260
Cumulative in Palliative Care
Adults
6,151
Pediatrics
Cumulative on ART
Adults
Pediatrics
2,760
Time-to-failure:
Patients identified by both criteria
 Median time to
% Treatment Success
11.1 mo.
virologic failure
 11.1 months
Virologic Failure
15.3 mo.
Immunologic Failure
 Median time to CD4
failure
 15.3 months
 Viral load monitoring
identified failure
significantly earlier
than CD4 criteria
(p<0.0001)

Patients maintained on virologically non-suppressive ART over a median of 6
months developed an average of 1.96 IAS-mutations with a loss of 1.25
active drugs (Cozzi-Lepri et al. AIDS 2007; 21:721.)
TDF-3TC-NVP (n=813) is Inferior to AZT-3TC-NVP
multivariate analysis on virologic failure
Failure at 12 months was 16.1% for TDF-3TC-NVP versus 9.5%
AZT-3TC-NVP K.Scarsi et al. Vienna, 2010
PMTCT Transmission Rates (n=5320)
No statistically significant difference between ART and
mono or bi-ART prophylaxis
Meloni et al, 2010
Patient Monitoring:
Pharmacy Database Adherence Utility
-------------------------------------BLANKED OUT-----------------------------
• Assess adherence to treatment based on timeliness of drug
pick-ups
• Use calculation of average percent adherence
• Setting up networks so that pharmacists can cross-check
prescriptions
Ahmadu Bello University Teaching Hospital
Loss to Follow up Rate
Lower in ARV Experienced vs. Naïve Patients n= 3001
100%
Cohort 1 Naïve
Cohort 1 Experienced
Cohort 2 Naïve
Cohort 2 Experienced
Cohort 3 Naïve
Cohort 3 Experienced
% Lost to Follow-Up
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
1
2-3
4-6
7-9
10-12
Months on ART
13-18
19-24
25-30
31-36
Comparison of LTFU among Large
Treatment Programs in Africa
Country
# Patients
Analyzed
Duration of
Follow-up
LTFU rate
Comments: LTFU definition
South Africa
CID 2006; 43:770.
1235 pts
(Sep 02 -Aug
05)
35 months
33.3% early
mortality
(2.3% LTFU)
LTFU: >4 weeks late for
scheduled visits and were not
deaths or transfers
South Africa
JAIDS 2008;
47(1):101.
1631 pts
(Apr 04 - Jun
05)
15 months
16.4% LTFU
during 15 mo F/u
LTFU: >6 weeks with no visit or
pharmacy pick-up
Nigeria
PLoS 2010;
5(5):e10584.
5760 pts
(Mar 05 - Jul
06)
16 months
26% lost at any
time during 16
month follow-up
LTFU: Did not return >60 days
from expected visit
Risk factors: CD4>350 or <100,
etc.
Nigeria
ABUTH LTFU Data
3001 pts
(Jun 06 May 09)
35 months
22.6% LTFU at
12 months of
follow-up
LTFU: >2 months since missed
visit or pick-up
 Assessment of causes of early & late LTFU may elucidate potential
interventions
APIN/PEPFAR Sites: 2010
Federal Medical Centre Nguru
University of Maiduguri Teaching Hospital
State Specialist Hospital Maiduguri
Nursing Home Maiduguri
Ahmadu Bello University Teaching Hospital
University of Ibadan College of Medicine
3 Satellites under UCH
Adeoyo Maternity Hospital
43 Oyo DOTS Centres
Sacred Heart Catholic Hospital
Lantoro
Jos University Teaching Hospital
Our Lady of Apostles Hospital Jos
8 Satellite Hospitals, 44 PHCs
Federal Medical Centre Makurdi
University of Nigeria Teaching Hospital
68 Nigerian Military Hospital
Creek Hospital
Nigerian Institute for Medical Research
University of Lagos, College of Medicine
PHC-Iru Victoria Island
Sites Under APIN Ltd
Widowcare Abakiliki
Ebonyi
Lagos University Teaching Hospital
Mushin General Hospital
Onikan Women’s Hospital
Sites Under Harvard PEPFAR
APIN Program Office
• Continual training is a critical
foundation for optimal
prevention, treatment and care
programs and sustainability
• Rigorous program evaluation
is critical to inform national
guidelines and insure optimal
care.
• Developing systems for
program outcome and impact
will facilitate country ownership
and sustainability
Botswana
Tanzania
R. Marlink
W. Fawzie
P. Burns
G. Msamanga
T. Gaoloathe
D. Mtasiwa
J. Mukhema
G. Chalimilla
N. Ndwapi
S. Kaaya
I. Thior
C. Hawkins
M. Mine
S. Ismail
C. Bussmann
M. Mwanyika-Sando
Nigeria
P. Kanki
R. Murphy
J-L Sankalé
B. Chaplin
K. Scarsi
B. Taiwo
P. Okonkwo
E. Ekong
T. Jolayemi
R. Olaitan
S. Ochigbo
O. Idigbe
S. Ogunsola
M. Garbati
I. Adewole
D. Olaleye
D. Owujekwe
O. Eberndu
S.Meloni
S. Hosseini
H.Rawizza
A. Ojesina
K. Hurt
A.Dieng Sarr
J. Samuels
P. Akande
B. Aluko
S. Sagay
O. Agbaji
S. Akanmu
W. Gashau
C. Okany
R. Nkado
H. Muktar
J. Abah
N. Nulenga