The Implementation of the WHO Asia Pacific Treatment Metrics Dr. YU, Dongbao WHO Regional Office for...

The Implementation of the WHO Asia Pacific

Treatment Metrics

Dr. YU, DongbaoWHO Regional Office for the Western Pacific

20 July, 2014

Antiretroviral Treatment Roll-out in Asia: Using Big Data to Inform Policy

SUSA39, IAC Melbourne, 20 July 2014

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World Health Organization

Western Pacific Region

Why Metrics for the HIV cascade?

WHO Metrics: objective, principles, conceptual framework and indicators?

How to use the guide?

Examples of country implementation

Next steps

Outline of presentationOutline of presentation

Why metrics?

What is a cascade? What is a cascade?

• Evaluate the prevention and treatment benefit of ART• Provide information to improve HIV services • “…What is measured gets done” Dr. M. Chan, DG, WHO

• To achieve the outcome of viral suppression, each must progress along the continuum of care in a timely manner

• Delay and attrition contribute to mortality and HIV transmission

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Major features: Country needs, country led

Developed by WHO WPRO/SEARO and supported by CDC, USAID and other partners

Field tested in several countries

Minimum number of indicators: cascade & program

Step by step guidance on presentation, analysis and use of data

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Objectives and target audienceObjectives and target audience

Objectives: To assess and improve the effectiveness of HIV testing,

linkages, and retention along the cascade of HIV, TB/HIV and PMTCT services at national and subnational levels; and

To assist country program in prioritizing key indicators to monitor the cascade of HIV services from HIV testing to linkages to care and treatment.

Target audience: Program managers, staff and, Monitoring and Evaluation officers at national and subnational levels.

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Guiding principlesGuiding principles

Public health approach

Minimum number of indicators: 13 cascade & 8 programme indicators

National and subnational level use

Adaptation according to local context

Data use and action at all levels

% of pre-ART patients

retained in care

Diagnosis Enrollment in Care

Antiretroviral Treatment

Outcome(Viral suppression or MTCT)

Linkage to care Retention Retention

CASC

ADES

% of PLHIV enrolled in

care

PRO

GRA

MM

ECONCEPTUAL FRAMEWORK

% of ART patients

retained in care

Ratio (or %) of # PLHIV

newly enrolled in

care to # newly

diagnosed

CON

TIN

UU

M

OF

CARE

PMTC

T

% of TB patients tested for HIVTB

-HIV

HIV % of PLHIV

who know their status

% of pregnant women tested for HIV

% of eligible PLHIV

receiving ART

% of incident TB-HIV cases treated for TB & HIV

% of HIV-exposed infants tested within 2 months of birth

% of HIV-positive pregnant women whose partner has been tested

CD4 count at time of enrollment

% of key populations (SW, MSM, PWID) tested for HIV

% of PLHIV enrolled in care whose partner has been tested

% of months in reporting period with no ARV stock outs

% of on time drug pick up

% of PLHIV initiating ART within 30 days of eligibility

% of pregnant women with HIV who receive ARV drugs during pregnancy

% of HIV-exposed infants who receive ARV prophylaxis

% of PLHIV on ART with

undetectableVL

% of tested HIV-exposed infants who are HIV-positive

What are the indicators?

•Aware of HIV status•Uptake of HIV testing

by: TB patients; pregnant women

•Uptake of HIV testing by KP (SW, MSM, PWID); partners; EID

Linkage to HIV care and prevention

HIV testing

Eligibility assessmentPre-ART careRetention

Enrolment in care

Lifelong ART:Retention AdherenceSupplies

ART Initiation

Viral suppression

/ MTCT

•Ratio of newly enrolled to newly diagnosed

•Retention in pre-ART care

•CD4 count at enrolment

•Coverage of ART (overall, TB/HIV and PMTCT)

•Retention on ART

•Timely initiation of ART

•On-time drug pick-up

•ARV stock out

•Viral load suppression

•HIV+% infants

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Uses routine monitoring data at local level, plus estimation data at national level

Some indicators could be adapted Use visualized graphic presentation of:

• HIV services with cumulative cross sectional data and/or cohort data

• Cascade for TB/HIV services• Cascade for PMTCT• Dashboard

How to use the guide (1)

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Triangulate with other data sources when possible

Electronic data collection system with unique identifiers improves tracking of cascade of services

Analyse Identify Take Triangulate Gaps Action

How to use the guide (2)How to use the guide (2)

74,572

49,522

44,318

41038

7,896

1,406

0

10,000

20,000

30,000

40,000

50,000

60,000

70,000

80,000

Est. No. of PLHIV No. PLHIV diagnosed &Reported

PLHIV in care (pre-ART+ART) PLHIV receiving ART Retention (12 months) No. receiving VL VL suppressed

No

.Country Implementation Example 1:

Cascade of HIV services in Cambodia (2012)

1) Lack of unique identifier codes, unclear No. PLHIV, loss to follow up in care significant

2) Very few people get viral load test

3) Questionable viral suppression rate?

Action taken:1. Establish UIC2. Intensify follow up in care3. Improve viral load test

Country Implementation example 2: Cascade of HIV service 2009-2013 Lao PDR

Country Implementation example 2: Cascade of HIV service 2009-2013 Lao PDR

Est # of PLHIV Diagnosed Enrolled in care On ART Viral load test Suppressed VL0

1,000

2,000

3,000

4,000

5,000

6,000

7,000

5,955

3,600

1,345

22

6,250

4,272

1,690

263

6,412

4,942

1,988

519

6,704

5,559

2,375

678

7,039

6,238

2,787

1,022

1,954

2009

2010

2011

2012

2013

Nu

mb

er o

f p

eop

le

3.

Action taken: Presented in June 2014, and to be used by programme review in Aug. 2014.

Major findings:1. HIV testing and ART increasing2. Lack of UIC, and linkage of PLHIV

diagnosis and care weak3. Viral load testing increasing, but still

not enough.

1.

2.

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No. newly registered TB in year X No. HIV tested No. test HIV positive No. on ART and TB treatment0

500

1000

1500

2000

2500

3000

3500

4000

4500

5000

3848

1220

179 166

3999

1533

182

4306

2058

222118

4065

234 263

Diagnosis and treatment of TB/HIV co-infection in Lao PDR (2009-2013)

2009

2010

2011

2012

2013

Increased HIV testing among incident TB cases, but still a big gap.TB/ART treatment increased but still with gaps.

1

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No. Preg women diagnosed with HIV

No. HIV+ preg women receiving ARV

No. HIV exposed infants No. HIV exposed infants received prophylactic ARV

No. HIV exposed infants tested

0

100

200

300

400

500

1624

167

17

280

27

257

183

320

49

280

1729

298

49

298

32

366

55

Prevention of mother to child transmission in Lao PDR (2009-2013)

2009

2010

2011

2012

2013

1

2

1. Limited ARV for PMTCT2. Limited ART for HIV exposed in-fants3. Limited infants testing

3

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Country implementation example 3: Cascade of HIV services in the Philippines (2009-13)

Country implementation example 3: Cascade of HIV services in the Philippines (2009-13)

Est # of PLHIV Diagnosed Enrolled in care On ART Viral load test Suppressed VL0

5000

10000

15000

20000

25000

30000

35000

8700

835

14442

6015

1274

19335

8364

1992

23,923

11,702

3,492

1,552

32278

5564

2009

2010

2011

2012

2013

Nu

mb

er o

f P

eop

le

1

3

Key findings: Fast expanding No. PLHIVNo data on people on care, many loss to follow up during this stageViral load test limited and not recorded and reported

2

Action: Results presented to the national programme review

TB/HIV services in the Philippines (2009-13)TB/HIV services in the Philippines (2009-13)

No. newly registered TB in year X

2.1 den0

50,000

100,000

150,000

200,000

250,000

146,565

166,323

195,560

216,6271

No. HIV tested No. test HIV positive No. on ART and TB treatment0

500

1000

1500

2000

2500

3000

3500

4000

4500

1136

1300

205

1634

0

3917

1000

139

2040

460

0

796

525

2009

2010

2011

2012

2013

2

3

A high TB burden country, and increasingLimited HIV testing among TB patientsNo. of ART/TB treatment to be expanded

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A useful tool with promising results

Countries are encouraged to use at national and subnational levels

Actions are needed to improve the cascade of services

Some countries with significant data gaps and need to be addressed

ConclusionsConclusions

Next steps Advocacy: with partners on the use of the Asia

Pacific Treatment Metrics

Training: Workshop to be organized by WHO with technical partners for analysis and use of cascade data

Publication: Publish a WPRO progress report on cascade of HIV services, identify the major gaps for HIV, TB/HIV and PMTCT services, as well as gaps in data; and highlight actions needed

Acknowledgement

• Government partners from Cambodia, Viet Nam, China, Indonesia and Myanmar for their leadership and support

• Celine Daly and Tobi Saidel• Ying-ru Lo, Shweta Dhawan, Masami Fujita, Masaya Kato,

Nicole Seguy, Zhang Lan, Razia Pendse, Oscar Barreneche and colleagues from WHO, UNAIDS, CDC, USAID, FHI360

• Members of the Technical Advisory Group

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Thank you!Thank you!

Contact: Dongbao YuEmail: [email protected]

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