use of routine data to monitor, evaluate and enhance programs-- swaziland
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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. - PowerPoint PPT PresentationTRANSCRIPT
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