From HIV Testing to Treatment: Operations Research to Improve ARV Treatment Programs

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From HIV Testing to TreatmentOperations
Research to Improve ARV Treatment Programs

• Treatment Acceleration Program Meeting
• November 30, 2006
• Mark Micek, MD, MPH
• Health Alliance International
• University of Washington

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ARV expansion in Mozambique

• 1.7 million HIV-infected
• 270,000 need ARVs
• 30,000 on ARVs (8/06)
• 11 of those in need

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HAI in Mozambique

• Works exclusively with public sector
• Provincial/district/facility level support
• Sofala and Manica Provinces (27 and 19 HIV)
• Expansion of testing and ARV care sites
• 23 ARV care sites with 6,000 on ARVs
• OR
• National level support
• Maputo

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HIV Treatment Expansion Plan2006
Tambara
Guro
Chemba
Maringue
Macossa
HF Providing HAART (new) 17 (13) PLWHA
Registered () 36,270 (9) Eligible in HAART ()
5,250 (9) Children lt15 y in HAART ( of those
in HAART) 420 (8)
Cheringoma
Muanza
Sussundenga
Chibabava
2003
2004
2005
2006
Machanga
Machaze
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HIV Treatment Expansion Plan2008
Tambara
Guro
Chemba
Maringue
Macossa
HF Providing HAART (new) 53 (7) PLWHA
Registered () 100,490 (25) Eligible in HAART
() 23,903 (40) Children lt15 y in HAART ( of
those in HAART) 3,585 (15)
Cheringoma
Muanza
Sussundenga
Chibabava
2003
2004
2005
2006
2007
2008
Machanga
Machaze
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Testing is first step to entering HIV care system
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Why patients dont start HAART where are
patients lost?

• Step 1

Step 2
Step 3
Step 4
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Specific problems with targeted HIV testing

• Targeted HIV testing aimed at a specific group
• High-risk (TB, hospitalized)
• Special services available (pMTCT)
• Problems noted with testing ? treatment flow
• pMTCT
• TB patients

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How can we improve the efficiency of targeted HIV
testing?

• Changing counseling strategies
• Opt-in ? Opt-out
• Operational questions
• Will opt-out ? ? HIV testing?
• Will opt-out ? ? HIV treatment?
• Will opt-out ? ? HIV prevention? (another talk)

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Problem 1 Loss of pregnant women

• Year 2005 Beira (2 sites) and Chimoio (3 sites)
• 52 of pregnant women tested for HIV (opt-in)
• 28 of HIV arrived at an HIV clinic
• 68 VCT (difference plt.001)

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Possible solution change the testing strategy at
pMTCT sites
Strategy ?
Strategy ?

• 2005 vs. 2Q 2006
• ? testing by 535/mo (plt.001)
• ? HIV by 96/mo (plt.001)
• ? arrival to HIV clinic by 14/mo (p.07)

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Situation not unique

• UNICEF 2003 11 national pMTCT programs
• 49 of HIV women received ARV for pMTCT
• Kenya (Malonza, AIDS, 2003)
• 1249/1282 accepted test (97)
• Rapid tests associated with higher proportion
  receiving results (96 vs. 73, plt.001)
• No difference in receiving ARV for pMTCT (19 vs.
  11, p.2)
• Malawi (Manzi, Trop Med Int Health, 2005)
• 96 accepted test
• 45 of HIV and 34 of babies received SD-NVP
• Infant to follow-up 81 by 6-months

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Need to improve referral

• Improve counseling?
• Activists recruited to follow mothers (planned)
• Reduce stigma?
• Community mobilization
• Partner testing
• Decentralize care services?
• pMTCT sites with on-site HIV clinic 70
  referred
• CD4 testing (started in pMTCT sites 7/06)
• Clinical services (i.e. HAART)

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Problem 2 High loss of TB patients

• 2004-2005, TB sites in Beira city
• Few TB patients tested for HIV at local VCT
  (opt-in)
• New TB patients enrolled 250/mo
• TB patients tested for HIV 20/mo
• 8 of estimated TB-HIV patients enrolled into
  care at HIV clinic
• Operational questions
• Will opt-out ? ? HIV testing?
• Will opt-out ? ? HIV treatment?
• Micek, MA, Integrating TB and HIV Care in
  Mozambique Lessons from an HIV Clinic in Beira.
  CORE TB/HIV Case Study, The CORE Group,
  Washington DC, September 2004.

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Possible solution Change testing care for
patients in TB treatment
Old system
New system
TB patient treated at TB center
TB patient treated at TB center
Referred to VCT center for HIV testing
Opt-out HIV testing at TB center Rotating VCT
counselors TB nurses
If HIV
If HIV
Continue at TB clinic for TB treatment
Referred to HIV clinic for HIV
counseling Treatment of OIs CTX proph. HAART
Continue at TB clinic for HIV counseling TB
treatment CTX proph.
Referred to HIV clinic for HIV
counseling Treatment of OIs HAART
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Initial results

• Implemented in 6 TB facilities in Beira city, Sep
  05
• Indicators collected using routine data systems
• First 7mo (Sep 05 Mar 06)
• 1,290 patients tested for HIV
• 60 of all TB patients
• 916 (71) HIV-positive
• Additional 20 already knew status
• 834 (91) received CTX proph.
• 504 (55) registered at HIV clinic
• 128 (14) started HAART
• 25 of those arriving to the HIV clinic

• High acceptance from patients, TB staff and VCT
  counselors

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How to improve referral?

• Better counseling?
• Streamline treatment of TB patients at HIV
  clinic?
• Decentralize more HIV services to TB sites?
• CD4 counts
• HAART

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OR Center in Beira, Mozambique

• Collaboration between MOH, UW, HAI
• Support OR activities in central Mozambique
• Agenda development
• Involve policy personnel
• Technical support
• Protocol development
• Study management
• Analysis of results
• Training
• IRB review (future)

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Other examples of OR

• Improve follow-up at HIV care facilities
• Evaluate decentralization of HIV services to
  primary health care
• Follow-up
• Quality of care
• Improve HAART adherence
• mDOT
• Community-based treatment supporters
• Support human resource development
• Expand mid-level provider responsibilities
• Plan health worker allocation
• Retain health care workers

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Thank you