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ART Patient Monitoring

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					   ART Patient Monitoring

       Abdikamal Alisalad
      WHO, Country Office, Uganda



TAP/RAP, Maputo, 19-23 June 2006
Scaling up Prevention, Care & ART


                 Universal Access to
 From 3x5,
  2, 7, 10
                 prevention, care,
                 and treatment
Scaling up Prevention, Care & ART

Different    Care & treatment are live-
approach     long interventions
Scaling up Prevention, Care & ART

Different        treatment are live-long
approach         interventions
Decentralization To health centre level and
                 closer to communities
Scaling up Prevention, Care & ART

Different        treatment are live-long
approach         interventions
Decentralization To health centre level and
                 closer to communities
Feasible & for   Free services for those who
all              can’t afford
Scaling up Prevention, Care & ART

Different        treatment are live-long
approach         interventions
Decentralization To health centre level and
                 closer to communities
Feasible & for   Care & treatment are live-
all              long interventions
Monitoring       Adherence, switch 2nd line,
system           and resistence
Scaling up Prevention, Care & ART

Different
approach
Decentralization
                     Adequate human
                      and financial
Feasible & for
all                     resourses
Monitoring
system
     Interim Patient Monitoring
  Guidelines for HIV Care and ART
• Based on the HIV patient ART monitoring
  meeting
• WHO, UNAIDS, USAID, CDC, HRSA, GFATM
  and:
   – AIDS institute, EPICENTRE/MSF, ESTHER, FHI,
     infectious diseases institute, JSI/DELIVER,
     JSI/MEASURE, lighthouse, MCART association,
     MTCT-plus initiative, office of the US global AIDS
     coordinator, pan African treatment access movement,
     partners in health, PHARMAccess, SATELLIFE, St
     Camille medical Centre, VOXIVA, MSH, UNICEF,
     university of Brescia, university of cape town, USAID
• March 31, 2005 draft and subsequent drafts:
  http://www.who.int/3by5/
       Countries Using the Patient
           Monitoring System
•   Uganda
•   Zambia
•   Ethiopia
•   Tanzania
•   Lesotho
•   Malawi
•   India
•   Dominican republic
•   And others…
            TB Experience

• Standardized treatment card and
  register
• Globally standardized definitions
• Deliberate limitation of data collected
• Based on long experience
• Recently, new TB-HIV indicators
• Disease-specific (vertical)
  ART Patient Monitoring System

Patient monitoring system fills several
  roles:
   • For clinical team- to manage individual
     patients and groups of patients
   • For programme management: data for a
     few very important indicators
Patient monitoring can be:
   • Paper-based system
   • Electronic system
   • A combination of both
           What is the Patient Monitoring
                     System?

      Facility-based paper system has 6 items:
            1. A patient-held card
            2. A facility-held chronic care card
                 •   HIV Care/ART Card or
                 •   Same data elements in another format (ex.
                     Clinical record)
Kept at     3.   HIV Care Pre-ART register
facility
            4.   ART Register
            5.   Quarterly (or monthly) report
            6.   Cohort analysis report
     HIV+ patient
                            Patient-held card
       enrols in
     chronic HIV
         care


                                                Side 1: Summary card
                                                Update from Encounter card
    HIV care / ART                              as needed
    patient card
                                                        Side 2: Encounter card
                                                        Updated with each
                                                        outpatient visit for patients
                                                        in HIV care/ART
        New patients
        entered into
         pre-ART
          register



   Pre-ART register


                                                       Monthly or Quarterly HIV
                                                          Care/ART Report


         When ART
      starts, transfer to
        ART register
                                                      Number enrolled and eligible but not
                                                       yet started on ART
                                                      New and cumulative number enrolled
      ART register                                     in ART and HIV Care
                                                      Number receiving each ARV regimen
                                                       at end of reporting period



        Electronic entry
         using PDA or                                 ART Cohort Analysis Report:
           laptop by
         district team
                                                        At 6 mo, 12 mo, yearly


 District electronic database
                                                      Treatment regimens
     for cohort analysis                              Treatment outcome
disaggregated by sex and age                          Functional status
                                                      CD4
     ART Monitoring at Different
   Levels of the Health Care System

     LEVEL           TOOLS             PURPOSE          QUANTITY

Global/Regional Summary           3x5, PEPFAR,            Less
                indicators        UNGASS..etc
National        Summary           National planning &
                indicators        evaluation
District        Summary           District planning &
                indicators        reporting
Facility        Registers/logbook QoC, drug supply,
                                  clinical team
                                  building
Patient         Patient           Case management
                card/records                             More
 Policy guidelines for ART              NATIONAL

       ART coverage                     DISTRICT

      ARV stock outs

   Training HWs for ART
  Health systems for ART




                                           FACILITY
Comprehensive care coverage

 Eligible pts receiving ART


                              PATIENT
 Continuation of treatment
Survival @ 6, 12, 24 months
                       Indicators
1. Indicators related to patient access to HIV care and ART
   • Number currently on ART
   • Proportion of people with advanced HIV infection
       receiving ART (UNGASS)
2. Indicators related to success of ART (national core
   indicators)
   • Continuation of first-line regimens at 6, 12 and 24
       months after initiation
   • Survival at 6, 12, 24, 36, etc. Months after initiation of
       treatment
3. Other indicators
   • HIV drug resistance early warning indicators
   • Other indicators for facility-level programme monitoring
   • TB/HIV indicators
   • Prevention indicators
         Core national ART programme indicators

Core 1   Existence of national policies, strategy and guidelines for ART programmes
Core 2   Percentage of districts or local health administration units with at least one health facility providing
             ART services in line with national standards
Core 3   Percentage of ARV storage and delivery points experiencing stock-outs in the preceding 6 months
Core 4   Number of health workers trained on ART delivery in accordance with national or international
            standards
Core 5   Percentage of health facilities with systems and items to provide ART services
Core 6   Percentage of health facilities with ART services that also provide comprehensive care, including
             prevention services, for HIV-positive clients
Core 7   Percentage of people with advanced HIV infection receiving ARV combination therapy
Core 8   Continuation of first-line regimens at 6, 12 and 24 months after initiation
Core 9   Survival at 6, 12, 24, 36, etc. months after initiation of treatment


Source: World Health Organization (WHO). National AIDS programmes: a guide to indicators for
monitoring and evaluating national antiretroviral programmes. Geneva, WHO, 2005.
                        Pre-ART Register



Information for one patient


• Chronic care register v. acute care register

• Each row is one patient

• Collect information on a group of patients

• Lists ALL patients who enrol in HIV care
                              ART Register
                       ART start-up groups             Each page (A3-
                       based on month/year              A3) has only
 Unique
                           start ART in                one ART start-
patient ID
                           programme                     up group
       COHORT: Year _______ Month ________               ART Register 2004-2005




Each row is one patient




                                 Records patient                      Supports
                                status at 6, 12, 24,               cohort analysis
                                    etc. months
          2004             January


     Jan Feb M A M J Jul




                   In
Month 6
  Minimum standardized essential
         data elements
I.     Demographic information
II.    HIV care and family status
III.   ART summary
IV.    Patient encounter information




 Source: Patient monitoring guidelines for HIV care and ART
                    ART Summary
•   ART history prior to entry
•   ART START date/ treatment cohort:
•   Date medically eligible to start ART
•   Why medically eligible; baseline CD4, clinical stage
•   Date medically eligible AND ready to start ART
•   Date medically eligible, ready AND selected to start ART
•   Functional status and weight at ART start
•   First line regimen
•   Original first line regimen (list drugs)
•   If SUBSTITUTE within first-line regimen: dates, reasons, new
    regimens
•   If SWITCH to or SUBSTITUTE within second-line regimen or more:
    dates, reasons, new regimens
•   ART interruptions: dates, reasons
•   STOP ART: dates, reasons
•   ReSTART: dates
•   Transfer In, Transfer Out: date, facility transferred from or to
•   LOST (temporary): dates
•   DROP/Lost to follow-up: dates
•   DEAD: date
                ART Cohort analysis:
            at 0, 6, 12, 24, etc. months


                In




                                            National Core 8
Treatmen                                     ART Indicator
    t
regimens
Treatmen                  National Core 9
    t                      ART Indicator
outcomes
  CD4

Functiona
 l status


Adherenc
   e
             Quarterly Report: Table 4




• Core 7
• 3 by 5
• UNGASS
Total currently
on ART
Other indicators for facility-level
     programme monitoring
     Benefits of Building an ART Monitoring System
       as a HealthMapper Application Extension

 Use HealthMapper's existing geographical data

 Use HealthMapper – DataManager common functionalities to
  append additional geographical and health data

 Real time map production of ART data

 Have access to additional mapping functionalities
   – Maps showing aggregated/disaggregated data over time
     and/or geography
   – Display additional geographical data in correlation with ART
     data
              HealthMapper ART Monitoring Extension
                           Data Entry
Monthly or Quarterly HIV Care/ART Report               ART Cohort Analysis Report




   Data entry can be customized for each country
   User-defined validations can be created
   New calculated fields can be added
   Customizations are automatically applied on both the Report & Data Exchange
    functionalities
            HealthMapper ART Monitoring Extension
                  Data Reporting and Analysis
Monthly or Quarterly HIV Care/ART Report                ART Cohort Analysis Report




 Can generate batch reports for each selected features of a given level
    – Disaggregated: at Health Facility level for a single time period
    – Aggregated: at Health Facility or above level for a given time range
 Can generate aggregated reports for all selected features of a given level
           HealthMapper ART Monitoring Extension
            Data Reporting and Analysis: OUTPUT
                All Health Facility Monthly Reporting form data Aggregated




 Country specifics are automatically applied on reports output
           HealthMapper ART Monitoring Extension
            Data Reporting and Analysis: OUTPUT
                        All cohort data of all Health Facilities
                        Aggregated – Grouped by Outcomes




 Country specifics are automatically applied on reports output
           HealthMapper ART Monitoring Extension
            Data Reporting and Analysis:OUTPUT
                   All cohort data of all Health Facilities Aggregated
                     Grouped by Outcomes and sorted by Cohorts




 Country specifics are automatically applied on reports output
ART SITES & NUMBER OF PATIENTS ON ART BY DISTRICT, Northern Region, March 2006




                                                       = 1 ART SITE


                                                       < 105
                                                       105 – 491
                                                       492 – 879
                                                       879 – 1265
         HealthMapper ART Monitoring Extension
           Data Reporting and Analysis: MAPS




 All ART Indicators are directly
  connected to the HealthMapper
  database
   – all ART indicators can be
       shown on maps
   – all HealthMapper GIS
       functionalities are available
Thanks for Listening

				
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