The document discusses metrics for monitoring the cascade of HIV services across the continuum of care. It presents a conceptual framework showing the cascade from diagnosis to viral suppression. Key metrics are identified to measure progress at each stage, including the percentage of people living with HIV who know their status, are linked to care, initiated on antiretroviral therapy, and have achieved viral suppression. The metrics were field tested in two countries and found useful for program assessment. Challenges include data quality and capacity at the local level. Guidelines will be published in early 2014 to help countries use these metrics to identify gaps and improve program performance.

1. Metrics for Monitoring the
Cascade of HIV Services
Dr Yu Dongbao
WHO Regional Office for the Western Pacific
21 Nov. 2013
FHI360/WHO Session: Improving the HIV Cascade of Services:
Advances in Reducing Loss to Follow Up between HIV Testing, PreARV Care and Sustained Adherence to ARV. 21 Nov. 2013 Hall G

2. Outline
 What are the Metrics
 How to use the metrics
 Issues/challenges and plan
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World Health
Organization
Western Pacific Region

3. Let’s fix it…
Source: FHI360

4. What are the Metrics?
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World Health
Organization
Western Pacific Region

5. TB‐HIV
PMTCT
PROGRAMME
CASCADES
HIV
CONTINUUM
OF CARE
CONCEPTUAL FRAMEWORK
Enrollment in
Care
Diagnosis
Retention
Linkage to care
% of PLHIV
who know
their status
Ratio (or %)
of # PLHIV
newly
enrolled in
care to #
newly
diagnosed
Antiretroviral
Treatment
% of PLHIV
enrolled in
care
% of
pre‐ART
patients
retained in
care
Outcome
(Viral suppression or MTCT)
Retention
% of eligible
PLHIV
receiving
ART
% of ART
patients
retained in
care
% of TB patients
tested for HIV
% of incident TB‐HIV cases treated
for TB & HIV
% of pregnant women
tested for HIV
% of pregnant women with HIV who
receive ARV drugs during pregnancy
% of PLHIV on
ART with
undetectable
VL
% of HIV‐exposed infants who
receive ARV prophylaxis
% of key populations (SW, MSM,
PWID) tested for HIV
CD4 count at time of
enrollment
% of PLHIV initiating ART within 30
days of eligibility
% of PLHIV enrolled in care whose
partner has been tested
% of on time drug pick up
% of HIV‐positive pregnant women
whose partner has been tested
% of months in reporting period
with no ARV stock outs
% of HIV‐exposed infants tested
within 2 months of birth
% of tested HIV‐exposed infants
who are HIV‐positive

6. Objectives and target audiences
• Objectives:
To identify the bottlenecks and gaps along the cascade of HIV
services; and
To assist national programmes in prioritizing key indicators to
monitor the cascade of HIV services
• Target audience: program managers, staff and
M&E officers at national and subnational levels

7. How to use the Metrics?
Uses routine monitoring data at local level,
plus estimation data at national level
Use visualized graphics or dashboard
Triangulate with other data sources when
possible
Electronic data collection system with
unique identifiers improves tracking of
cascade of services
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World Health
Organization
Western Pacific Region

8. The field test …
 Field test in Cambodia and Viet Nam, with data collected from
China, Indonesia and Myanmar in Oct. 2013
 Purpose: To validate the data availability and usefulness
 Results:
 The metrics provide useful framework for programme
assessment and data interpretation
 All indicators can be calculated using aggregated data, but
unique identifier code (UIC) would improve the monitoring
 Adapt the indicators and analysis to country situation as
necessary
 Capacity building required at subnational level
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World Health
Organization
Western Pacific Region

9. Example of cascade analysis (1):
Too many people are not aware of their HIV status
Cascade of HIV diagnosis to care, China, 2012
900000
800000
700000
600000
500000
400000
300000
200000
100000
0
100%
49.5%
42.3%
21.9%
Est. No. of PLHIV
in 2012 *
No. PLHIV
diagnosed &
Reported
15.5%
PLHIV in care PLHIV still on ART No. receiving VL
(pre‐ART+ART)
13.2%
VL suppressed
Source: * UNAIDS 2013, NCAIDS China, WHO-UNAIDS National AIDS Programme Managers Meeting, Feb 2013
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World Health
Organization
Western Pacific Region

10. Example of cascade analysis (2):
Too many people are lost after diagnosis
300,000
Cascade of HIV diagnosis to care, Vietnam, 2012
256,845
250,000
Many lost after diagnosis
201,703
200,000
150,000
82,241
100,000
Many 72,711 after diagnosis
loss
50,000
n.a
Estimated of
PLHIV *
n.a
PLHIV
PLHIV in care
PLHIV
No. receiving
VL
diagnosed
(precurrently
VL
suppressed
and reported ART+ART) receiving ART
Source: * UNAIDS 2013, VAAC Vietnam, WHO-UNAIDS National AIDS Programme Managers Meeting, Feb 2013
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World Health
Organization
Western Pacific Region

11. Issues and challenges
•
•
•
•
•
Local vs. national use: local capacity
Programme data vs. estimation data
Definition of and monitoring retention of “care”
Cohort vs. cross sectional analysis
Use of data and programmatic actions

12. The Guide and timeline…
 The Asia Pacific Metrics for Monitoring Cascade of HIV
Services contains:
 A framework
 Core indicators: cascade and programme indicators
 Guide on data presentation, analysis and interpretation
 Guide on use of the Metrics for programme improvement
 Timeline: finalization by Dec. 2013; and publish in early
2014
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World Health
Organization
Western Pacific Region

13. In summary…
• A useful tool for improve the linkages and
retention across the full cascade of services and
reduce loss to follow up
• There are issues/challenges: capacity, data quality,
and UIC, etc…
• Suggestions and inputs welcome

14. Acknowledgement
• Government partners from Cambodia, Viet Nam, China,
Indonesia and Myanmar for their leadership and support
• Celine Daly and Tobi Saidel
• Ying‐ru Lo, Masami Fujita, Masaya Kato, Nicole Seguy,
Zhang Lan, Razia Pendse, Oscar Barreneche and
colleagues from WHO, UNAIDS, CDC, FHI360,
• Members of the Technical Advisory Group

15. Thank you!
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World Health
Organization
Western Pacific Region