What Do We Know About Adherence in ICAP Programs?: A Review of the Data
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Transcript of What Do We Know About Adherence in ICAP Programs?: A Review of the Data
Supporting Sustainable Adherence to HIV Prevention, Care & TreatmentICAP Technical WorkshopOctober 19-22, 2009Kigali, Rwanda
ICAP Adherence Data
Molly McNairy, MD, MSc
To Review
Patients on ART in resource-limited settings can have good immunologic and virologic outcomes
Rates of adherence and barriers to adherence similar across settings
LTFU increases over time (5X higher > 2-3 years)
LTFU relationship with mortality 40-50% of LTFU dead
Rosen 2007, McPherson 2008
Meta-Analysis: Adherence at 2 years
Rosen et al. PLoS 2007 32 studies in SSA 1996-2007 ~75,000 patients in non-research ART 6 mo = 80% pts retained 12 mo = 60% pts retained
At 2 Years*: BEST CASE = 84% WORST CASE = 46% AVERAGE = 61%
~40% LTFU at 2 yearsOf which, LTFU 56%, Death
40%
61% at 24 months
A closer look at ICAP
Adherence Data June 2009URS, PFaCTS, Patient-level
“Those are other programs”
Data Sources
URS data LTFU varies across countries Often means 90 days since last visit
Patient-level data LTFU from care = 12 months since last
clinic LTFU from treatment= 6 months since last
clinic PFACTs
Adherence program characteristics
Two-year cumulative risk of death, loss to follow-up9, and loss to program8
among all patients since enrollment into care (Total 204,000)
WORST CASE SCENARIO:204,000 patients50% at 2 years100,000 patients LTFU?
Application for ICAP Sites
Two-year cumulative risk of death, loss to follow-up9, and loss to program8
among ART patients since ART initiation (Total 91,612 patients)
Pediatric ART patients since ART Initiation Patient level data through June 2009 (n= 28 sites)
0 0.5 1 1.5 250%
55%
60%
65%
70%
75%
80%
85%
90%
95%
100%
ICAP data
20% Default
40% default
Time (years)
# p
ati
ents
on t
reatm
ent
Applying the Meta-Analysis ResultsTo ICAP Adherence Data
*Rosen et al PLoS Med 4 (10) 2007
“Good Adherence>95%”
Our GAP
38504
38869
39234
39600
39965
0
50,000
100,000
150,000
200,000
250,000
300,000
350,000
Reported dead
Lost to follow up
Cumulative initiating ART
ART patients retained in care
Cumulative and current enrollment in ART care
at ICAP-supported HIV care and treatment programs
as of June 2009 (n= 327,092)
Nu
mb
er
of
pati
en
ts
5%
34%
62%
10.3% per
year on ART
Status of ART patients at ICAP sitesJune 2009 (n= 327,092)
*Includes patients who transferred out while on ART.
.59% per year
on ART
5.3% per year
on ART
Lost to Follow-
up
Reported Dead
Stopped ART
Continued ART, 265,251 81%*
Discontinued ART, 61,841
19%
PFaCTS Data on Adherence services
Type of patient support service Type of adherence service # outreach workers Methods for tracking missed appointments Time to follow-up/tracking
Sites offering on-site patient support services (n=323)
% s
ites
wit
h
serv
ice
ART Adher-ence Support
Outreach Peer educa-tor program
Food support for children and infants
Food support for adults
0%
50%
100% 98%
57%
33%37%
22%
Take Home: All sites have services, but what are those services doing?
Overall (N =
448)
Cote d'Ivoire
(N =
15)
Ethiopia (N =
49)
Kenya (N =
100)
Lesotho (N
= 31)
Mozambique (N
= 47)
Nigeria (N
= 29)
Rwanda (N =
42)
South Africa (N
= 32)
Swaziland (N
= 25)
Tanzania (N
= 78)
0
20
40
60
80
100
Peer Educator ProgramsPFaCTS round 4 (January-June
2009)
% o
f sit
es
64%
Overall (N = 462)
Cote d'Ivoire (N
= 15)
Ethiopia (N = 50)
Kenya (N = 101)
Lesotho (N = 31)
Mozambique (N = 47)
Nigeria (N
= 29)
Rwanda (N = 46)
South Africa (N
= 32)
Swaziland (N
= 31)
Tanzania (N = 80)
0
20
40
60
80
100
Type of adherence servicesPFaCTS Round 4 (Jan-Jun 2009)
Any Adherence Support Program1Counseling more than once a monthDedicated pharmacist, team pharmacist, and/or routine medication pickup reviewEducational and/or reminder tools2
% o
f site
s
Mean number of outreach workers at ICAP-supported HIV care and treatment sites
(n=183)
Mean n
um
ber
of
outr
each
w
ork
ers
Overa
ll
Moz
ambi
que
South
Afri
ca
Cote
d'Ivo
ire
Tanza
nia
Leso
tho
Ethio
pia
Rwanda
Niger
ia
Zambi
a
Kenya
0.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
1.4
3.1
2.0
1.51.4 1.4
1.31.1
0.70.5
0.3
Cote d'Ivoire
Ethiopia
KenyaLesotho
Mozambique
NigeriaRwanda
South Africa
Swaziland
Tanzania
Overall
0
5
10
15
20
25
30
35
# o
f o
utr
ea
ch w
ork
ers
/1,0
00
act
ive
A
RT
pa
tie
nts
Siteswith an outreach program
Number of outreach workers per 1,000 active ART patients at ICAP sites with at least 1 dedicated outreach worker,
PFaCTS Round 4 (Jan-Jun 2009)
n=8 n=48 n=18 n=11 n=17 n=39 n=24n=8 n=1 n=33 n=207
Note: The bubbles represent the median across sites and the bars represent the IQR.
Prevention Services Offered at ICAP Sites
92%95%
92%
78%
63%
19%
94% 96%
84%78%
67%
31%
0%
50%
100%
Counseling regarding disclosure
Education on behavior and
safe sex
Provision of condoms
Referral for on-site screening
for STIs
Education on high-risk
substance abuse
Screening for drug and
alcohol abuse
Jul-07 Jul-08
% s
ites
Total (N = 324)
Cote d'Ivoire (N = 10)
Ethiopia (N = 24)
Kenya (N = 91)
Lesotho (N = 18)
Mozambique (N = 23)
Nigeria (N = 27)
Rwanda (N = 44)
South Africa (N
= 32)
Swaziland (N = 12)
Tanzania (N = 43)
0
20
40
60
80
100
Appointment Register (%) Pharmacy Records (%) Database (%)
% o
f s
ite
sMethods of identifying patients with missed ap-
pointments in ICAP-supported care and treatment sites with an outreach program, PFaCTS
round 4 (Jan-Jun 2009)
Total (N = 324)
Cote d'Ivoire (N
= 10)
Ethiopia (N = 24)
Kenya (N = 91)
Lesotho (N = 18)
Mozambique (N = 23)
Nigeria (N
= 27)
Rwanda (N = 44)
South Africa (N
= 32)
Swaziland (N = 12)
Tanzania (N = 43)
0
20
40
60
80
100
Phone calls/letters (%) Home visits (%) Check hospital records (%)
% o
f site
sFirst step in tracing patients with missed appoint-
mentsPFaCTS round 4 (Jan-Jun 2009)
Total (N = 324)
Cote d'Ivoire (N
= 10)
Ethiopia (N = 24)
Kenya (N = 91)
Lesotho (N = 18)
Mozambique (N = 23)
Nigeria (N
= 27)
Rwanda (N = 44)
South Africa (N
= 32)
Swaziland (N = 12)
Tanzania (N = 43)
0%
20%
40%
60%
80%
100%
> 10 days (%) Within 6- 10 days (%) Within 5 days (%)
% o
f site
s
Time between missed appointment and contact attempt for ART patients
PFaCTS Round 4 (Jan-Jun 2009)
Measuring Adherence to Treatment Lack of ICAP structured measurement
tools Difficult to measure
Patient level Lost to treatment program & treatment
interruptions Clinical records Patient self-report, pill count, recall
Surrogate measures Treatment failure Second line regimens
Overall Rwanda South Africa Ethiopia Lesotho Nigeria Mozambique
Kenya Tanzania0%
50%
100%
83%
95% 94%92%
89%
79%
74% 73%
65%
44%
74%
57%
46% 45%
36%34%
39%
27%
43%
69%
44%39%
46%
35%
40%43%
31%
Baseline 6-Month 12-Month
Proportion of patients with CD4 count at baseline, 6, and 12 months after ART initiation
% p
ati
en
ts w
ith
CD
4 c
ou
nt
n=9,921
n=7,420n=13,420 n=25,854
n=10,683
n=9,55
7
n=8,497
n=114,694
n=29,342
Overa
ll
Cote
d'Iv
oire
Ethi
opia
Keny
a
Leso
tho
Moz
ambi
que
Rwan
da
Sout
h Afri
ca
Tanz
ania
-0.3%
0.0%
0.3%
0.6%
0.9%
1.2%
1.5%
All sitesAmong sites with >=1 patients on second line regimens
% A
ctiv
e A
RT
pa
tie
nts
on
se
con
d-l
ine
re
gim
en
sProportion of adult ART patients on second line regimens in
ICAP supported care and treatment sites, June 2009
Note: Restricted to sites that report >=90% of regimen data
LTFU is a complicated term ICAP has LTFU rates similar to other large ARV
programs 40% ART pts LTFU at 2 years (worst case)
Yet, ICAP has >98% of sites reporting adherence programs and multi-level pt support services > 75% sites report counseling more than 1 month,
dedicated adherence pharmacist, and remember/education tools
>85% of sties report having appointment registers > 70% sites report capacity for patient tracking with
phone calls, home visits Average of 6 outreach workers/1000 ART patients
How can we strengthen our adherence support services?
In Summary