1. ICAP Adherence Data Molly McNairy, MD, MSc Supporting Sustainable Adherence to HIV Prevention, Care & Treatment ICAP Technical Workshop October 19-22, 2009Kigali, Rwanda

3. Meta-Analysis: Adherence at 2 years Rosen et al. PLoS 2007 32 studies in SSA 1996-2007 ~75,000 patients in non-research ART 6 mo = 80% pts retained 12 mo = 60% pts retained At 2 Years*: BEST CASE = 84% WORST CASE = 46% AVERAGE = 61% ~40% LTFU at 2 years Of which, LTFU 56%, Death 40% 61% at 24 months

4. A closer look at ICAP Adherence Data June 2009 URS, PFaCTS, Patient-level “Those are other programs”

8. Two-year cumulative risk of death, loss to follow-up9, and loss to program8among ART patients since ART initiation (Total 91,612 patients)

9. Pediatric ART patients since ART Initiation Patient level data through June 2009 (n= 28 sites)

10. Applying the Meta-Analysis ResultsTo ICAP Adherence Data “Good Adherence>95%” Our GAP *Rosen et al PLoS Med 4 (10) 2007

11. Cumulative and current enrollment in ART care at ICAP-supported HIV care and treatment programsas of June 2009 (n= 327,092) Cumulative initiating ART Lost to follow up Reported dead Number of patients ART patients retained in care

12. Status of ART patients at ICAP sites June 2009 (n= 327,092) 10.3% per year on ART Lost to Follow-up 5.3% per year on ART Reported Dead .59% per year on ART Stopped ART *Includes patients who transferred out while on ART.

13. PFaCTS Data on Adherence services Type of patient support service Type of adherence service # outreach workers Methods for tracking missed appointments Time to follow-up/tracking

14. Sites offering on-site patient support services (n=323) Take Home: All sites have services, but what are those services doing? % sites with service

15. 64%

17. Mean number of outreach workers at ICAP-supported HIV care and treatment sites (n=183) Mean number of outreach workers

18. Number of outreach workers per 1,000 active ART patients at ICAP sites with at least 1 dedicated outreach worker,PFaCTS Round 4 (Jan-Jun 2009) n=8 n=48 n=18 n=11 n=17 n=39 n=8 n=33 n=207 n=24 n=1 Note: The bubbles represent the median across sites and the bars represent the IQR.

19. Prevention Services Offered at ICAP Sites % sites

22. Time between missed appointment and contact attempt for ART patients PFaCTSRound 4 (Jan-Jun 2009)

24. Lost to treatment program & treatment interruptions

25. Clinical records

26. Patient self-report, pill count, recall

27. Surrogate measures

28. Treatment failure

30. Proportion of adult ART patients on second line regimens in ICAP supported care and treatment sites, June 2009 Note: Restricted to sites that report >=90% of regimen data

32. ICAP has LTFU rates similar to other large ARV programs

33. 40% ART pts LTFU at 2 years (worst case)

34. Yet, ICAP has >98% of sites reporting adherence programs and multi-level pt support services

35. > 75% sites report counseling more than 1 month, dedicated adherence pharmacist, and remember/education tools

36. >85% of sties report having appointment registers

37. > 70% sites report capacity for patient tracking with phone calls, home visits

38. Average of 6 outreach workers/1000 ART patientsHow can we strengthen our adherence support services?