The Implementation of the WHO Asia Pacific Treatment Metrics

1. Antiretroviral Treatment Roll-out in Asia: Using Big Data to Inform Policy SUSA39, IAC Melbourne, 20 July 2014 The Implementation of the WHO Asia Pacific Treatment Metrics Dr. YU, Dongbao WHO Regional Office for the Western Pacific 20 July, 2014

2. Outline of presentation • Why Metrics for the HIV cascade? • WHO Metrics: objective, principles, conceptual framework and indicators? • How to use the guide? • Examples of country implementation • Next steps

3. What is a cascade? • To achieve the outcome of viral suppression, each must progress along the continuum of care in a timely manner • Delay and attrition contribute to mortality and HIV transmission Why metrics? • Evaluate the prevention and treatment benefit of ART • Provide information to improve HIV services • “…What is measured gets done”Dr. M. Chan, DG, WHO

4. Major features: • Country needs, country led • Developed by WHO WPRO/SEARO and supported by CDC, USAID and other partners • Field tested in several countries • Minimum number of indicators: cascade & program • Step by step guidance on presentation, analysis and use of data

5. Objectives and target audience Objectives: • To assess and improve the effectiveness of HIV testing, linkages, and retention along the cascade of HIV, TB/HIV and PMTCT services at national and subnational levels; and • To assist country program in prioritizing key indicators to monitor the cascade of HIV services from HIV testing to linkages to care and treatment. Target audience:Program managers, staff and, Monitoring and Evaluation officers at national and subnational levels.

6. Guiding principles • Public health approach • Minimum number of indicators: 13 cascade & 8 programme indicators • National and subnational level use • Adaptation according to local context • Data use and action at all levels

7. CONCEPTUAL FRAMEWORK CONTINUUM OF CARE Retention Retention Linkage to care HIV CASCADES % of PLHIV who know their status Ratio (or %) of # PLHIV newly enrolled in care to # newly diagnosed % of PLHIV enrolled in care % of eligible PLHIV receiving ART % of ART patients retained in care % of PLHIV on ART with undetectable VL % of pre-ART patients retained in care TB-HIV % of TB patients tested for HIV % of incident TB-HIV cases treated for TB & HIV % of pregnant women tested for HIV % of tested HIV-exposed infants who are HIV-positive % of pregnant women with HIV who receive ARV drugs during pregnancy PMTCT % of HIV-exposed infants who receive ARV prophylaxis PROGRAMME % 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 on time drug pick up % of PLHIV enrolled in care whose partner has been tested % of months in reporting period with no ARV stock outs % of HIV-positive pregnant women whose partner has been tested % of HIV-exposed infants tested within 2 months of birth

8. What are the indicators? • Aware of HIV status • Uptake of HIV testing by: TB patients; pregnant women • Uptake of HIV testing by KP (SW, MSM, PWID); partners; EID Linkage to HIV care and prevention Eligibility assessment Pre-ART care Retention Lifelong ART: Retention Adherence Supplies HIV testing Enrolment in care ART Initiation Viral suppression / MTCT • Viral load suppression • HIV+% infants • Coverage of ART(overall, TB/HIV and PMTCT) • Retention on ART • Timely initiation of ART • On-time drug pick-up • ARV stock out • Ratio of newly enrolled to newly diagnosed • Retention in pre-ART care • CD4 count at enrolment

9. How to use the guide (1) • Uses routine monitoring data at local level, plus estimation data at national level • Some indicators could be adapted • Use visualized graphic presentation of: • HIV services with cumulative cross sectional data and/or cohort data • Cascade for TB/HIV services • Cascade for PMTCT • Dashboard

10. How to use the guide (2) • Triangulate with other data sources when possible • Electronic data collection system with unique identifiers improves tracking of cascade of services Analyse Identify Take Triangulate Gaps Action

11. 1) Lack of unique identifier codes, unclear No. PLHIV, loss to follow up in care significant 2) Very few people get viral load test 3) Questionable viral suppression rate? Action taken: Establish UIC Intensify follow up in care Improve viral load test

12. Country Implementation example 2: Cascade of HIV service 2009-2013 Lao PDR Major findings: HIV testing and ART increasing Lack of UIC, and linkage of PLHIV diagnosis and care weak Viral load testing increasing, but still not enough. 1. 2. Action taken: Presented in June 2014, and to be used by programme review in Aug. 2014.

15. Country implementation example 3: Cascade of HIV services in the Philippines (2009-13) 2 Action: Results presented to the national programme review

16. TB/HIV services in the Philippines (2009-13)

17. Conclusions • A useful tool with promising results • Countries are encouraged to use at national and subnational levels • Actions are needed to improve the cascade of services • Some countries with significant data gaps and need to be addressed

18. Next steps • Advocacy: with partners on the use of the Asia Pacific Treatment Metrics • Training: Workshop to be organized by WHO with technical partners for analysis and use of cascade data • Publication: Publish a WPRO progress report on cascade of HIV services, identify the major gaps for HIV, TB/HIV and PMTCT services, as well as gaps in data; and highlight actions needed

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

20. Thank you! Contact: Dongbao Yu Email: yud@wpro.who.int