International Experiences in Developing the HIV Service Cascade. RESPOND Conference, June 2015 Shirley Ko, Health Advisor, Pact

Transcription

1 International Experiences in Developing the HIV Service Cascade RESPOND Conference, June 2015 Shirley Ko, Health Advisor, Pact

2 HIV Cascade of Care Model that outlines the sequential stages, or continuum, of medical care that PLHIV go through from initial diagnosis to goal of viral suppression For PLHIV to fully benefit from antiretroviral therapy, they must be engaged and retained along the continuum

3 Where did the cascade originate? Concept borne out of data in the U.S. that showed only 25% of PLHIV had achieved the national HIV/AIDS treatment goal of viral suppression (2011) Cascade showed that patients were lost at each stage Analysis used to identify gaps in services, develop strategies to improve engagement in care, and target resources Led to establishment of the HIV Care Continuum Initiative in the USA (2013) Growing recognition worldwide that failure across the HIV cascade is a major barrier to achieving universal access to ART and viral suppression of sufficient magnitude to control the epidemic

4 Experience of HIV cascade in Georgia Reference: Chkhartishvili N, Sharvadze L, Chokoshvili O et al. The cascade of care in the Eastern European country of Georgia. HIV Medicine 2014; 16: Evaluation of Georgian cascade included all adult (18+ years) HIVinfected patients diagnosed from * Georgian cascade is an important contribution to our understanding of treatment programs in EECA region, where countries typically have similar HIV epidemiology and health systems

5 HIV Epidemic in Georgia (by transmission categories) Total reported HIV cases Newly reported HIV cases IDU, 49.4% Hetero, 41.6% Undetermin ed, 0.8% Blood transfusion, 0.5% Vertical, 1.8% Male-tomale sex, 5.9%

6 Georgian HIV response National HIV/AIDS Treatment & Care Program, since 1995 The Global Fund project, since 2004 Universal access to ART treatment, since 2004 Hepatitis C treatment among HIV patients, since 2011 Programs target PWID, MSM, FSW and prisoners One national AIDS and four regional AIDS centers All services are provided free of charge Robust electronic HIV/AIDS health information system

7 Evolution of ART guidelines CD4 <500 cells/mm 3 CD4 <350 cells/mm 3 ART initiation: CD4 <200 cells/mm 3 CD4 <250 cells/mm 3

8 Evolution of ART guidelines Regardless of CD4 cell count 2015? 2016? CD4 <500 cells/mm 3 CD4 <350 cells/mm 3 ART initiation: CD4 <200 cells/mm 3 CD4 <250 cells/mm 3

9 Georgian HIV Cascade 84% 88% 78% 80%

10 Georgian HIV Cascade 100% 84% 73% 57% 45% 84% 88% 78% 80%

11 Cascade of Care:

12 Taking the cascade one step back 49% 41% 36% 28% 23% Georgia 49% 84% 88% 78% 80%

13 Taking the cascade one step back 51% undiagnosed Low testing coverage: FSW 42%; MSM 34%; IDU 15% Missed opportunities to diagnose HIV in healthcare settings Low coverage with prevention interventions 49% 84% 88% 78% 80%

14 What does the cascade tell us? Patients diagnosed with HIV infection are successfully engaged in clinical care However, nearly half of estimated HIV-infected individuals remain unaware Significant gap in HIV testing/diagnosis is result of low testing coverage of key populations and missed opportunities to diagnose HIV infection in health care settings Large number of undiagnosed individuals are likely contributing to the majority of new HIV infections Late HIV diagnosis has serious implications for ART success at individual and population levels

15 Late Diagnosis: Economic Implications National AIDS program expenditures per person-year (excludes costs of ART)

16 Strengths & Limitations Mature electronic HIV information system provides cross-sectional snapshot of situation at a single point in time However, does not capture longitudinal dynamics (e.g., viral load suppression in a patient can change) Limited comparability of findings - no unified set of indicators for the cascade yet at both national and global levels WHO is developing metrics for monitoring the cascade

17 Conclusions for Georgia Cascade is a useful tool for visually demonstrating the strengths and identifying gaps in ART delivery programs Significant gaps in HIV testing/diagnosis requires scale-up Reducing the number of persons living with undiagnosed HIV infection + simultaneously enhancing engagement in continuous care will be important for achieving maximum individual and public health benefits of ART

18 HIV Cascade Toolkit: Vietnam

19 HIV Cascade Toolkit: Vietnam Developed and published by FHI 360 (2014) Supported by USAID and PEPFAR Builds on WHO s Metrics for Monitoring the Cascade for HIV Testing, Care and Treatment Services in Asia and the Pacific (2014) Practical how-to guide for HIV program implementers government, civil society at national, province levels Outlines steps for generating cascades Adaptable to other contexts/settings

20 Vietnam HIV Cascade

21 Use of Cascade Fosters a culture of data use Usefulness is heavily influenced by quality of available data o Routine data quality assurance procedures are important o Use of UIC is helpful for monitoring linkages between services and tracking individuals as they transition from services and locations Consistency in use of core indicators is critical Cascade is important but not the only tool for HIV service planning and quality improvement efforts o Can be used with service mapping, QI monitoring, epidemic modelling, gender/policy/service access assessments

22 Use of Unique Identifier Codes Cascade without UIC Cascade with UIC

23 Building a HIV cascade What? Identify the kind of cascade to be used. Where? Determine geographic area of focus or scope. What service area(s) will be emphasized? Who? Identify the population. When? Plot the time period. How? Distinguish presentation format.

24 Examples of different cascades Stacking cascade bars

25 Examples of different cascades Stacking cascade bars

26 Examples of different cascades Stacking cascade bars

27 Overall Considerations Cascades are a powerful starting point for further understanding the client flow, service delivery, and linkages across preventioncare continuum Interpretation of cascade data is enhanced by triangulation with other sources of data/information HIV program performance is affected by several factors, including quality and content of services; accessibility and acceptability; available resources; referral systems; and structural environment Discussions with stakeholders on cascade can provide further assistance on role of policies, health systems, communities and individuals to address barriers and facilitators to service uptake

28 Thank you!