Developing indicators for retention: The ICAPTanzania Perspective

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Developing indicators for retention The
ICAP-Tanzania Perspective
Dr. Harriet Nuwagaba-Biribonwoha 2-October-2007 IC
AP Annual Meeting, Nairobi, Kenya
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Background

• ICAP began supporting HIV care and treatment
  services in Tanzania in 2004 at MNH in Dar es
  salaam
• October 2006 regionalisation of USG partners
• ICAP supporting Pwani, Kagera, and Kigoma regions
  on the mainland and Zanzibar
• By June 30th 2007, ICAP supported 24 HIV Care and
  Treatment Clinics CTCs

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ICAP-supported regions and sites
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Indicators for retention PEPFAR/MOH

• Current patients in care comparison between
• Number enrolled
• Number who attended for care during the quarter
• Includes both pre-ART and ART patients
• Current patients on ART comparison between
• Number started on ART
• Number still on ART at the end of the quarter

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The Tanzanian Experience Data sources

• Tanzania has one recommended ME system at all
  CTCs
• The patient registration and follow-up card CTC
  2 card is the primary data record
• From October 2006 standard pre-ART and ART
  registers and appointment books introduced
• CTC 2 cards feed into the registers and a
  standard NACP CTC Access database
• Current patients previously reported using CTC3
  daily attendance register, led to
  over-reporting

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The Tanzanian Experience data use

• Indicators reported quarterly
• All sites use the paper systems, in addition
  electronic databases at 6 sites
• Collating of quarterly reports to observe trends
  over time
• Retention in care and on ART examined by age,
  sex, and region
• Feedback of data to Program and Implementing
  staff
• Review and discussion of results, strategising on
  way forward

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Definition of patient outcomes

• Only done for patients on ART
• Current on ART Patient still on ART at the end
  of the reporting quarter
• Lost to follow-up Patient has not attended the
  clinic for 3 months consecutively and their vital
  status is unknown
• Died Patients reported dead from hospital
  records and other sources e.g. community
  activities
• Transferred out Patient moved to another
  facility for care and treatment
• Stopped ART Patient is no longer taking ART
• Retention Current on ART / (Ever started ART -
  Transferred out) x 100

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Where outcomes overlap

• Transferred out and stopped ART categories
  fixed
• If patient transferred out, then was lost to
  follow-up, or died or stopped ART, count as
  transferred out.
• If patient stopped ART, then died, or transferred
  out, or was lost to follow-up, count as stopped
  ART.
• If patient stopped ART and then re-started or
  transferred out then came back to the site-
  counted as current in care
• Lost to follow-up category dynamic
• If patient is lost to follow-up, then transfers
  out, count as transferred out.
• If patient is lost to follow-up, then dies, count
  as died.
• If patient is lost to follow-up, then stops ART,
  count as stopped ART.

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June 2007 status of ADULT patients who started
ART between 2005 and 2007
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Adult Patients Enrolled

• 15,187 adults enrolled
• 5,029 (33) male, 10,158 (67) female
• 10,200 (67) received care during the quarter
• 3,385 (33) male, 6,815 (67) females

Table 1 Number of adults enrolled and receiving
care during the quarter by region.
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Adult ART patients
7,611 adults started on ART and 6,170 (81) still
on ART by June 2007 85 retention
Table 2 June 2007 ART status at the end of by
region
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June 2007 status of adults started on ART from
2005-2007 at all ICAP-supported sites
June 2007 ART follow up 81 still on ART 85
retention
loss to follow-up 518 (7) death 527(7)
transfer out 311 (4) stopped 85 (1)
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June 2007 status of adults started on ART from
2005-2007 in Kagera region
June 2007 ART follow up 83 still on ART 86
retention
loss to follow-up 175 (5) death 223 (6)
transfer out 121 (4) stopped 73 (2)
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June 2007 status of adults started on ART from
2005-2007 in Pwani region
June 2007 ART follow up 79 still on ART 84
retention
loss to follow-up 280 (10) death 167 (6)
transfer out 131 (5) stopped 9 (lt1)
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June 2007 status of adults started on ART from
2005-2007 in Zanzibar
June 2007 ART follow up 74 still on ART 77
retention
loss to follow-up 50 (8) death 83 (14)
transfer out 23 (4) stopped 3 (lt1)
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June 2007 status of adults started on ART from
January to June 2007 in Kigoma region
June 2007 ART follow up 86 still on ART 90
retention
loss to follow-up 13 (2) death 54 (7)
transfer out 36 (5) stopped 0 (0)
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June 2007 status of adults started on ART from
2005-2007 by sex
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June 2007 status of CHILDREN who started ART
between 2005 and 2007
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Pediatric Patients

• Enrolment
• 1,247 children enrolled
• 584 (47) male, 663 (53) female
• 899 (72) children received care in Apr-Jun 2007
• 414 (46) male, 485 (54) female
• Pediatric patients on ART
• 569 children started ART
• 276 (49) male, 293 (51) female
• 453 (80) still on ART, 82 retention
• 214 (47) male, 239 (53) female

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June 2007 status of children started on ART from
2005-2007 at all ICAP-supported sites
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June 2007 status of children started on ART from
2006-2007 in Kagera region
June 2007 ART follow up 79 still on ART 81
retention
loss to follow-up 11 (5) death 23 (10)
transfer out 8 (4) stopped 5 (2)
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June 2007 status of children started on ART from
2006-2007 in Pwani region
June 2007 ART follow up 76 still on ART 79
retention
loss to follow-up 27 (12) death 15 (7)
transfer out 7 (3) stopped 3 (2)
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June 2007 status of children started on ART from
2006-2007 in Zanzibar
June 2007 ART follow up 83 still on ART 89
retention
loss to follow-up 0 (0) death 8 (10)
transfer out 5 (6) stopped 1 (1)
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June 2007 status of children started on ART from
January to June 2007 in Kigoma region
June 2007 ART follow up 93 still on ART 93
retention
loss to follow-up 0 (0) death 3 (7)
transfer out 0 (0) stopped 6 (0)
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June 2007 status of children started on ART from
2005-2007 by sex
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June 2007 status of children started on ART from
2005-2007 by age
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June 2007 status of children started on ART from
2005-2007 by age and sex
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Summary

• Enrolled patients 67 in adults and 72 in
  children still in care
• ART patients 81 adults and 80 children still
  on ART, retention 85 and 82 respectively
• Main reasons for not being on ART are
• Death 7 adults and 13 children
• LTFU 7 and 5 children
• Retention higher among females than males
• Adults 85 of females and 81 of males
• Children 87 of females and 81 of males
• More mortality among male children?
• Retention differences by region highest
  retention in Kigoma and lowest in Pwani

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Way forward

• Identify causes of LFTU and mortality
• Clinical care? - Poor adherence?
• Psychosocial factors? - Lack of support?
• Poor nutrition? - Late ART initiation?
• Strategies to determine status of patients LTFU-
  likely that mortality is underestimated
• Programmatic strategies to decrease mortality,
  and prevent LTFU
• ME to continue regular updates of patient
  retention data
• Address limitations of these data- other
  predictors of LTFU/mortality e.g. time, ongoing
  process for DQA
• Indicator refinement and addressing patients
  retention among pre-ART patients
• District network approach engaging district
  teams in retention activities

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Defining patient outcomes is important!
Yiannoutsos et al 2007. Evaluation of PEPFAR
programs in western Kenya
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Retention in patient cohorts

• Reported using revised tools from January 2007
• Figure shows number of person in specific cohorts
  over time

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Acknowledgements

• Magdaliz Gorritz Global Health Fellow, Columbia
  University
• ICAP-TZ ME team
• Site staff- data clerks, CTC coordinators
• ICAP-TZ program implementation team
• ICAP MER-NY
• GoT and Donors