What Do We Know About Adherence in ICAP Programs?: A Review of the Data
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  • 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
  • 2. To Review
    Patients on ART in resource-limited settings can have good immunologic and virologic outcomes
    Rates of adherence and barriers to adherence similar across settings
    LTFU increases over time
    • (5X higher > 2-3 years)
    LTFU relationship with mortality
    • 40-50% of LTFU  dead
    Rosen 2007, McPherson 2008
  • 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”
  • 5. Data Sources
    URS data
    • LTFU varies across countries
    • 6. Often means 90 days since last visit
    Patient-level data
    • LTFU from care = 12 months since last clinic
    • 7. LTFU from treatment= 6 months since last clinic
    PFACTs
    • Adherence program characteristics
  • Application for ICAP Sites
    Two-year cumulative risk of death, loss to follow-up9, and loss to program8among all patients since enrollment into care (Total 204,000)
    WORST CASE SCENARIO:
    204,000 patients
    50% at 2 years
    100,000 patients LTFU?
  • 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%
  • 16.
  • 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
  • 20.
  • 21.
  • 22. Time between missed appointment and contact attempt for ART patients
    PFaCTSRound 4 (Jan-Jun 2009)
  • 23. Measuring Adherence to Treatment
    Lack of ICAP structured measurement tools
    Difficult to measure
    • Patient level
    • 24. Lost to treatment program & treatment interruptions
    • 25. Clinical records
    • 26. Patient self-report, pill count, recall
    • 27. Surrogate measures
    • 28. Treatment failure
    • 29. Second line regimens
  • Proportion of patients with CD4 count at baseline, 6, and 12 months after ART initiation
    % patients with CD4 count
    n=8,497
    n=9,921
    n=7,420
    n=13,420
    n=25,854
    n=10,683
    n=9,557
    n=29,342
    n=114,694
  • 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
  • 31. In Summary
    • LTFU is a complicated term
    • 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 patients
    How can we strengthen our adherence support services?