ICAP Data Dissemination Meeting

August 31, 2011

Number of activities at currently supported facilities as of June 2011Nu

mbe

r of f

acili

ties

Source: ICAP Site Census, June 2011Note: Some facilities offer more than one activity.

Total Kenya Tanzania Mozambique Nigeria Lesotho South Africa Cote d'Ivoire Ethiopia Swaziland DR Congo Rwanda Zambia0

500

1000

1500

2000

25002,443

792687

196 176124 132 117

8563

14 532

15757

2 19 19 10 1 47 2

Num

ber o

f fac

ilitie

sNumber of facilities ever supported and transitioned

by ICAP as of June 2011

Source: ICAP Site Census, June 2011

Number of facilities ever supported by ICAP

Number of facilities transitioned or in transition

ICAP accomplishments as of June 2011 (1)• 1.3 million patients enrolled into HIV care in

~900 facilities– 672,000 (52%) initiated ART– 58,000 (9%) <15 years of age– 380,000 (68%) of 560,000 patients enrolled in facilities that

report TB screening data screened at enrollment• 1.8 million pregnant women HIV tested at ANC in

~ 1700 facilities– 113,000 (6%) tested positive + 20,000 (1%) known positive– 96,000 (72% of all positive) received ARV prophylaxis,

including 12,000 who received triple therapy

• 3.7 million people tested for HIV in ~1000 facilities– 1.7 million (46%) tested in Ethiopia

• ~1 million HIV simple rapid tests and ~650,000 CD4 count tests processed in ~500 laboratories

ICAP accomplishments as of June 2011 (2)

Ongoing activities

• Lab PfaCTS on-going (138/739 labs completed)• Care and treatment PfaCTS round 6 on-going

(107/763 sites completed)• Capacity building indicators in development

• DataBytes• ICAP data dissemination webinars• ICAP methodology webinars

New data dissemination and use initatives

Data dissemination webinars

• April 6: Baseline characteristics and outcomes among youth enrolled in ICAP-supported care and treatment facilities (Matt Lamb)

• November TBD: Priority indicators (Suzue Saito)

Methodology webinars• June 22: Using aggregate data for program monitoring and

evaluation: Case study examining decentralization of pediatric care and treatment services for HIV (Suzue Saito, Ruby Fayorsey)

• September 22: Methods for addressing implementation research questions: experiences from ICAP studies (Harriet Nuwagaba-Biribonwoha)

• October 13: Basic epidemiologic measures of disease occurrence (Bill Reidy)

• November TBD: Using routinely-collected data to estimate patient retention in care and after ART initiation at ICAP-supported HIV care and treatment facilities (Matt Lamb)

• December 7: Estimation of population size for most at-risk populations (Anna Deryabina)

Trends in ART retention at ICAP-supported care and treatment sites

Batya ElulSuzue Saito

Source: Holmes,C. PEPFAR’s Contributions to the Global Scale‐up of Treatment. Joint WHO & UNAIDS Annual Consultation on Global Forecasts of Antiretroviral Demand9 December, 2010.

Source: Cornell et al, 2010

Methods (1)• PEPFAR retention indicator: No. patients still on ART at

initiating site at 6/12 months divided by no. who initiated ART 6/12 months earlier– Patients ≤6 years and transfers out excluded– Reported quarterly for successive cohorts of patients

initiating ART: 5812 6-m cohorts and 5338 12-m cohorts

• Plotted trends over time in retention for July 2004 - June 2011

• Used relative risk regression to assess crude and adjusted relative risk of non-retention per 1 quarter increase in ART initiation date

• Excluded first 2 quarters to account for data quality issues at start-up

Methods (2)

Median proportion of patients initiating ART included in 6/12 month cohorts, by country

6 month cohort 12 month cohort IQR across quarters

Cote d'Ivo

ire

Ethiopia

Kenya

Leso

tho

Mozambiq

ueNige

ria

Rwanda

South

Africa

Tanza

nia

All countr

ies0%

20%

40%

60%

80%

100%

Perc

ent i

nclu

ded

1/1/20

05

1/1/20

06

1/1/20

07

1/1/20

08

1/1/20

09

1/1/20

10

1/1/20

110%

25%

50%

75%

100%

0

100

200

300

400

500

600

80%, 295

79%, 19384

83%, 95

73%, 20343

Reporting Quarter

Perc

ent r

etai

ned

Number of clinics

Cohort retention (6 and 12 months) after ART initiationat ICAP-supported facilities, all countries

Trend : P=0.7299

Trend: P=0.0844

Note: Significance testing for trend analysis reflects crude RR of retention per 1 unit increase in reporting quarter.

1/1/20

09

1/1/20

10

1/1/20

110%

25%

50%

75%

100%

0

10

20

30

40

50

42%, 205

55%, 517

75%, 12

45%, 488

Reporting Quarter

Perc

ent r

etai

ned

Number of clinics

Ethiopia Côte d'Ivoire

Trend : P<0.0001

Trend: P<0.0001

Trend : P<0.0001

Trend: P<0.0001

Note: Significance testing for trend analysis reflects crude RR of retention per 1 unit increase in reporting quarter.

Cohort retention (6 and 12 months) after ART initiation at ICAP-supported facilities

1/1/20

06

1/1/20

07

1/1/20

08

1/1/20

09

1/1/20

10

1/1/20

110%

25%

50%

75%

100%

0

10

20

30

40

50

60

70

76%, 7081%, 2094

59%, 747

73%, 2240

Reporting Quarter

Perc

ent r

etai

ned Num

ber of clinics

Data entry error

7/1/20

06

7/1/20

07

7/1/20

08

7/1/20

09

7/1/20

100%

25%

50%

75%

100%

0

5

10

15

20

25

30

35

64%, 382 74%, 1436

64%, 140 64%, 1499

Reporting Quarter

Perc

ent r

etai

ned

Number of clinics

Trend: P=0.2857

Lesotho Kenya

Note: Significance testing for trend analysis reflects crude RR of retention per 1 unit increase in reporting quarter.

Cohort retention (6 and 12 months) after ART initiation at ICAP-supported facilities

Trend : P= 0.8220

1/1/20

05

1/1/20

06

1/1/20

07

1/1/20

08

1/1/20

09

1/1/20

10

1/1/20

110%

25%

50%

75%

100%

0

20

40

60

80

100

120

140

160

75%, 77 82%, 4586

79%, 22391%, 3629

Reporting Quarter

Perc

ent r

etai

ned

Number of clinics

Trend : P=0.0717

Trend: P=0.5247

10/1/

2007

10/1/

2008

10/1/

2009

10/1/

2010

0%

25%

50%

75%

100%

0

5

10

15

20

25

30

3586%, 12781%, 1754

71%, 127

68%, 3489

Reporting Quarter

Perc

ent r

etai

ned

Number of clinics

7/1/20

05

7/1/20

06

7/1/20

07

7/1/20

08

7/1/20

09

7/1/20

100%

25%

50%

75%

100%

0

10

20

30

40

50

60

88%, 173

78%, 507593%, 14

69%, 4728

Reporting Quarter

Perc

ent r

etai

ned

Number of clinics

Mozambique Nigeria

Trend : P=0.0609

Trend: P=<0.0001

Trend : p=0.4302

Trend: P=0.3939

Note: Significance testing for trend analysis reflects crude RR of retention per 1 unit increase in reporting quarter.

Cohort retention (6 and 12 months) after ART initiation at ICAP-supported facilities

1/1/20

05

1/1/20

06

1/1/20

07

1/1/20

08

1/1/20

09

1/1/20

10

1/1/20

110%

25%

50%

75%

100%

0

10

20

30

40

50

100%, 18

88%, 80100%, 23

79%, 52

Reporting Quarter

Perc

ent r

etai

ned

Number of clinics

1/1/20

07

1/1/20

08

1/1/20

09

1/1/20

10

1/1/20

110%

25%

50%

75%

100%

0

10

20

30

4090%, 50

77%, 3117

93%, 28

50%, 3970

Reporting Quarter

Perc

ent r

etai

ned

Number of clinics

No reports

South AfricaRwanda

Trend : P=0.0039

Trend: P=0.1162

Trend : P=0.5424

Trend: P=0.0077

Note: Significance testing for trend analysis reflects crude RR of retention per 1 unit increase in reporting quarter.

Cohort retention (6 and 12 months) after ART initiation at ICAP-supported facilities

1/1/20

05

1/1/20

06

1/1/20

07

1/1/20

08

1/1/20

09

1/1/20

10

1/1/20

110%

25%

50%

75%

100%

0

20

40

60

80

100

120

92%, 4974%, 2,161

100%, 269

67%, 1,747

Reporting Quarter

Perc

ent r

etai

ned

Number of clinics

Tanzania

Trend : P=0.4748

Trend: P=0.8395

Note: Significance testing for trend analysis reflects crude RR of retention per 1 unit increase in reporting quarter.

Cohort retention (6 and 12 months) after ART initiation at ICAP-supported facilities

Adjusted RR* of non-retention after ART initiation per quarter increase in start date

* Adjusted RR of retention per 1 unit increase in reporting quarter. Adjusted for age, sex, CD4 at ART initiation, facility type, and location. Bolding indicates significance at α=0.05 level.

Country RR 95% CI RR 95% CI

6 months 12 months

All countries 1.00 0.99, 1.01 1.01 1.00, 1.02

Côte d'Ivoire 1.05 1.03,1.07 1.06 1.04, 1.09

Ethiopia 0.98 0.97, 0.99 0.98 0.97, 0.99

Kenya 0.99 0.97, 1.00 0.99 0.97, 1.01

Lesotho 1.00 0.97, 1.03 1.00 0.97, 1.04

Mozambique 1.01 0.99, 1.04 1.01 0.98, 1.04

Nigeria 1.02 1.00, 1.04 1.04 1.03, 1.06

Rwanda 1.00 0.97, 1.02 1.03 1.00, 1.05

South Africa 1.02 1.00, 1.04 1.00 0.99, 1.02

Tanzania 1.00 0.99, 1.01 1.00 0.99, 1.01

0.0

1.0

2.0

Adjusted RR (95% CI) for 6-month and 12-month non-retention after ART initiation

% women on ART

2ry/3ry vs. 1ry Urban-city vs. rural

Semi-urban vs. rural

Quarter % children on ART

Private vs. 1ry CD4 ≤ 200 at ART initiation

Adju

sted

Ris

k Ra

tio

6 months after ART initiation, adjusting for age, sex, CD4 at ART initiation, location, and facility type 12 months after ART initiation, adjusting for age, sex, CD4 at ART initiation, location, and facility type

Jan-05

Apr-05

Jul-05

Oct-05

Jan-06

Apr-06

Jul-06

Oct-06

Jan-07

Apr-07

Jul-07

Oct-07

Jan-08

Apr-08

Jul-08

Oct-08

Jan-09

Apr-09

Jul-09

Oct-09

Jan-10

Apr-10

Jul-10

Oct-10

Jan-11

Apr-11

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

83%

79%

80% 75%71%

71%73%

85%83.0% 82.0% 72.0%

ICAP: Percent retained 6 months ICAP: Percent retained 12 months Cornell: Percent retained 12 months

Reporting Quarter

Perc

ent r

etai

ned

Retention at ICAP-supported sites in context

Fox and Rosen meta-analysis:• 39 cohorts, 226,000 adults• 6 month retention: 86%• 12 month retention: 78%

Conclusions (1)

• Retention in ICAP-supported sites is on par with that observed in other cohorts and has remained steady over 7 years of scale-up

• After adjusting for sex, age, CD4 at ART initiation, facility type, and location, cohort retention over time shows:– Overall no significant change in 6 m retention– Nominal decrease in 12 m retention– Significant improvement in 6 and 12 m retention in ETH– Nominal decrease in retention in CI (6 & 12 m), NG (6 & 12 m),

SA (6 m), and RW (12 m)

Conclusions (2)• Decrease in cohort retention in CI, NG, SA, RW likely due to:

– Increase in number of facilities supported– Increase in number of patients enrolled (increase in cohort size)– Emphasis on de-centralization (undocumented transfers)– In some settings, political or labor strife– Data errors or change in definition

• Relative risk for non-retention:– Higher risk for cohorts in higher- vs. lower-level sites

(Decentralization?)– Higher risk for cohorts with lower median CD4 cell counts– Lower risk for cohorts with greater proportion of women initiating

ART

Thanks. . .

• Matt Lamb• Wafaa El-Sadr• David Hoos• Michelle Moses-Eisenstein• Country teams• Tedd Ellerbrock