Use of Routine Data to Monitor, Evaluate and Enhance Programs-- Swaziland

Wafaa El-Sadr, Velephi Okello, Margaret McNairy, Tanya Ellman, Altaye Kidane, Pido Bongomin,

Harrison Kamiru, Jessica Justman and Ruben Sahabo

ICAP at Columbia University and Ministry of Health in Swaziland

Rapid Scale-Up of Treatmentin Swaziland

Population: 1.2 million

HIV Prevalence: 32% (18-49 y) (SHIMS 2011)HIV incidence: 2.4 per 100PY, (SHIMS 2001)

Men: 1.7 Women: 3.1

Est. number of PLWH: 172,800 (2011)Facilities providing ART services: 134Number on ART: 101,730 (2013)

Adults 93,787 Children: 7,943

Ever enrolled on ART: 133,420

2011 2012 20130%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

71%

80%

75%

85%

94%

87%

80%

94%

82%

ART Coverage by Gender by Year

Male female Total

ICAP support for Swaziland Scale-up of Care and Treatment, 2009 to 2014

March 2014: 112 sites

• Support for three of four regions: Hhohho, Manzini, and Lubombo

• Technical assistance• National and site support• Health systems strengthening• Number of ART sites supported:

112• Currently on ART: 73,737• Ever enrolled on ART: 110, 351

Cumulative Number of Patients Initiating ART at ICAP-supported Sites, Oct 2009-Mar 2014: Swaziland

By March 2014, 110,351 patients had ever initiated ART at ICAP-supported sites.

8% of patients were children

110,351

2010 2014

Challenge: Reaching Targets

Oct-Dec 2011

Jan-Mar 2012

Apr-Jun 2012

0

2,000

4,000

6,000

8,000

10,000

12,000

New and cumulative patients on ARTYear 3 Only

New on ART Cumulative on ART

Quarterly Data from SAPR

Num

ber o

f pati

ents

Target = 11,296 by Oct 2012

Ever attended HIV care among HIV-infected patients with CD4 < 350

SHIMS, 2012

Approach to Address Gap in ART Initiations

1. Adapt a cascade approach to improve number of ART initiations

2. Identify baseline data to operationalize the cascade

3. Identify and prioritize interventions to address gaps

4. Identify priority sites5. Introduce cohort methodology

Continua/Cascades of Care

1. Identify steps in the Relevant Cascade

• Number of persons test HIV positive • Number of persons enroll in HIV care• Number of persons assessed for ART eligibility

(WHO, CD4+ cell count) • Number of persons eligible for ART• Number of persons initiated ART

2. Identify baseline data to operationalize cascade

Siphofan

eni C

linic

Shew

ula Clin

ic

Tikhuba C

linic

Mpolonjeni C

linic

Ndzevan

e Clin

ic

Lomahash

a Clin

ic

Vuvulan

e Clin

icSP

HU

Gilgal C

linic

Simunye

Lubuli Clin

ic

Ubombo

Sincen

i Clin

ic

Nkonjwa C

linic

Sitsat

sawen

i Clin

ic

Manyev

eni C

linic

Sigcaw

eni

0

20

40

60

80

100

120

140

160

180

200

ART cascade, Lubombo Region facilities, Oct 2011 - Mar 2012

Enrolled in pre-ART Had WHO stage/CD4 at baselineART eligible Started ART

Num

ber p

atien

ts

3- Choose and Prioritize Interventions: Focusing Matrix

IMPORTANCE

1(Least) 2 3 4 5

(Most)

1(Hardest)

2

3

4

5(Easiest)

Ease

of I

mpl

emen

tatio

n

Focusing Matrix

IMPORTANCE

1(Least) 2 3 4 5

(Most)

1(Hardest)

2

3

4

5(Easiest)

Ease

of I

mpl

emen

tatio

n

most important and easiest to implement – #1 priority

# 2 priority

Priority Interventions• Universal assessment of ART eligibility:

– Inconsistent use of WHO clinical staging– Job aide developed

• Rapid turnaround of CD4+ cell count results– Peers (Expert Clients) review lab registers for CD4+ test

results and call labs as needed• Scheduling of pre-ART patients for follow-up:

– Document appointments for subsequent clinic visit and ART eligibility assessment

– Peers make phone calls and if necessary conduct home visits for those who miss visits or unable to locate

Criteria Description Check if Yes

For CHILDREN

< 2 Years of age Any child HIV+ who is less than 2 year of age ☐

Thrush Oral candidiasis (thrush) which appears as white film lining the oral cavity for 2 weeks or more, after first 6 weeks of life

☐

Diarrhea Loose or watery stools for 2 weeks or more ☐

For ADULTS

TB Diagnosis of TB at any time in the past

or

Currently on TB treatment for > 2 weeks

☐

☐

Diarrhea Loose or watery stools for the past 1 month ☐

Thrush Oral candidiasis (thrush) which appears as white film lining oral cavity for 2 weeks or more

☐

Herpes Zoster Current Zoster (Shingles)

or

Previous Zoster by history or evidence of scars

☐

☐

Kaposi Sarcoma Rash of multiple dark raised lesions that can be found on face, body and extremities.

☐

• Prompt ART initiation- Designate staff member to identify all ART-eligible patients not yet initiated ART and place these patients’ folders in the “expected patient” box- Document the monthly number of ART-eligible patients yet to initiate

(goal of zero instituted) - On a weekly basis, peers and facility staff identify patients lost along the cascade and call them for follow-up

WHO Staging Tool

4. Choosing Priority SitesHighest Volume Lowest Performance

65% 80% 42%

55% 30% 75%

20% 85% 66%

40% 35% 80%

4. Choosing Priority SitesHighest Volume Lowest Performance

65% 80% 42%

55% 30% 75%

20% 85% 66%

40% 35% 80%

• 10 largest volume clinics in 3 regions = 30 sites• Volume defined by number of patients enrolling in

HIV care in the past quarter

5. Introduce Cohort Methodology

• Specify the best source of data for each step– Pre-ART register, patient HIV medical care file

• Design simple tools (paper, Excel) for abstracting and summarizing these data– Excel sheet for data collection/management– Graph to display cascade data over time

• Identify cohort members– Cohorts defined by month of pre-ART enrollment

• Plan for periodic data collection• Establish team to review data and engage in action plan

0

500

1000

1500

2000

2500

3000

3500

Pre-ART enrollment, ART eligibility, and ART initiations– Monthly cohortsN

umbe

r of p

atien

ts

Additional post-intervention cohort data to-be collected

Intervention roll-out begins

Baseline Cohort

Results

July 2012 Aug 2012 Sep 20120

200

400

600

800

1000

1200

Care Cascade IndicatorsJul-Aug 2012 cohorts

Enrolled in careHad CD4 or WHO stageEligible for ARTStarted ART

Cohort

Num

ber o

f pati

ents 85%

79%74%

90%89%

92%

66% 62%71%

Results of InterventionsProportion of Eligible Patients Initiating ART Increased from 63% to 81%

• Efforts in Q4 resulted in an increase to 81% of eligible patients initiating ART by May

• Findings from efforts informed target-setting for the following year

Maintenance of Targets• Since interventions implemented, continued success in

reaching targets for ART initiations• In the first two quarters of following project year, 5,883

adults and children were initiated on ART – 95% of target

ART Initiations, October 2013-March 2014

HIV Care Cascade

McNairy, El-Sadr AIDS 2012

Need for implementation science research to identify effective strategies

• Implementation Science study• Aim: to improve linkage to care and

retention in care• Objective: to evaluate the

effectiveness of a combination intervention strategy of biomedical, behavioral and structural interventions

• Anticipated Policy/Program implications: – Influence national policy

recommendations for linkage and retention targets and interventions

Study design • Cluster site randomized trial (study unit = HIV testing + care site)• SOC vs combination intervention strategy (CIS)

Interventions • POC CD4+ testing at HIV testing• Accelerated ART among eligible patients (1 week)• Care packages for pre-ART patients• SMS reminders• Financial incentives

Innovation • Combination strategy to match barriers• Cost effectiveness evaluation

Primary Outcome

• Linkage at 1 month + Retention at 12 month after HIV testing

SecondaryOutcomes

• Time to ART eligibility• Time from ART eligibility to initiation• New WHO III/VI event, hospitalization, death• Cost-effectiveness• Feasibility, acceptability

Timeline • July 2012-July 2015

Study Overview

HIV Care Cascade

McNairy, El-Sadr AIDS 2012

POC CD4

PackageOf

Care

Rapid ART Initiation

Financial Incentives

Conclusions• Enormous success has been achieved by Swaziland in the

scale-up of HIV treatment• Routine data is of substantial value in informing progress,

identifying gaps and guiding interventions• A step-wise process is critical to identify gaps, prioritize

actions and measure outcomes• Engagement of teams of providers and supervisors at

multiple levels is critical to achieve goals and objectives• Cohort approach allows for monitoring of progress • Implementation science research can inform program

design and implementation through identification of innovative strategies for enhancing program outcomes

Acknowledgement

• Support of the Ministry of Health in the Kingdom of Swaziland

• Staff and patients at health facilities • Partner organizations• Funding support by PEPFAR