Presentation: Results of National Adherence PHE

National HIV Prevention , Care and Treatment Program Adherence Technical Meeting October 19 th - 22 nd , 2009 Jules Mugabo M.D HIV, AIDS and STI Unit TRAC Plus/ Rwanda MOH TRAC Plus C enter for T reatment and R esearch on A IDS, M alaria, T uberculosis and O ther E pidemics

HIV Prevention Program HIV testing (VCT, PMTCT and PIT): Pregnant women and their partners under PMTCT Exposed children Couples and children in VCT Youth (youth at street) Sex workers and theirs clients Truck drivers Soldiers IEC/BCC Condom Family Planning

VCT National program 2004-2008 2004 2005 2006 2007 2008 Estimation of general population (census 2002) 8,577,753 8,814,253 9,058,392 9,309,619 9,567,190 Targeted population for VCT (50% of the general population) 4,288,877 4,407,127 4,529,196 4,654,810 4,783,595 % Of clients tested (denominator: Targeted population for VCT) 4.1% 10.2% 10.4% 16.1% 20.2% HIV seroprevalence in VCT 11.4% 9.4% 7.3% 4.8% 3.4% % of Health facilities offering VCT 26.5% 46.2% 51.8% 63.1% 75.4%

PMTCT Program 2004-2008 2004 2005 2006 2007 2008 Rwanda population (census 2002) 8,577,753 8,814,253 9,058,392 9,309,619 9,567,190 Expected pregnant women 351,688 361,384 371,394 381,694 392,255 % of pregnant women tested for HIV 27% 49% 59% 56% 75% % of HIV + women receiving ART prophylaxis 35% 51% 60% 55% 67% % of exposed children receiving ART prophylaxis 26% 33% 46% 65% 63% % of partners tested for HIV in PMTCT ND 32,6% 52,4% 65% 78% % of discordant couples in PMTCT ND 4,5% 3,7% 3,1% 2,7% % of Health facilities providing PMTCT 26.5% 46.2% 51.8% 63.1% 75.4%

Level of participation in PMTCT program

Barriers to PMTCT use The most mentioned barriers are: Ignorance : some healthy women do not understand the benefits of ANC Fear for HIV test and discrimination towards PLWHA : they cannot bear HIV+ status and discrimination that follows Extra marital pregnancies: unmarried girls, widows and single mothers do not attend ANC and PMTCT because they tend to hide their pregnancies

Barriers to PMTCT use Partner: some HIV+ women' partners who do not disclose, unwanted pregnancy do not utilize ANC or PMTCT Health facility: too long waiting time, lack of confidence in performing reliable lab tests, out of stock of ART, Painful physical exams, requirement of partner attendance,… Overwhelmed: women with many children fail to use ANC services because they are overwhelmed by housework Geographic accessibility: long distance can prevent pregnant women to attend required ♯ of ANC

Reasons for less adherence of pregnant women to PMTCT services 1 Out of health facility delivery: The main cause of delivering at home or in the street was that some women get surprised by the labor and deliver at home or before they reach the health facility. 2 Poverty : lack of money for transportation or for medical care, long distances, and lack of relatives to go with at health facility are reasons why they do not give birth in health facilities. Others: unwanted pregnancies ,…

PMTCT clients challenges and program weakness Breastfeeding: the mix of breastfeeding and complementary diet after six month because they can’t afford breastfeeding replacement: “… we are obliged to continue to breast feed our baby after though we know we are infected because we can’t let the baby starve” Required ♯(CPN) ANC: Misunderstanding of the importance of ANC, lack of support from husbands and relatives . Incomplete package of PMTCT services at some Health centers

HIV Care and Treatment OI prophylaxis (CTX, Dapsone, fluconazole…) Screening, diagnosis and management of: STI OI (TB, Cryptococcal meningitis Side effects Provision of ART Patients monitoring and follow up Psychosocial and adherence support Nutrition program Family Planning Prevention with positive PBF Community based intervention (HBM, IGA, OVC, Mutuelles,…)

ART Program 2004-2008 2004 2005 2006 2007 2008 Estimation of general population (census 2002) 8,577,753 8,814,253 9,058,392 9,309,619 9,567,190 Adults HIV+ adult (15+) 158,275 157,157 162,837 170,639 177,258 Adults in need of ARVs 50,106 48,733 49,316 52,949 92,421 Proportion of eligible adults receiving ART 18% 36% 64% 80% 62% Children HIV+ children (0-14) 29,373 29,621 29,878 30,275 31,299 Infants in need of ARVs 7,625 7,395 7,517 7,912 8,544 Proportion of eligible children receiving ART 7% 20% 37% 55% 66% Services coverage % of Health facilities offering 7% 18% 29% 36% 43%

Patients on ART end June 2009 = 70,234 patients) ARV regimen % patients 96.58 % of adults patients D4T+3TC+NVP 48.07 AZT+3TC+NVP 34.82 D4T+3TC+EFV 5.40 AZT+3TC+EFV 8.29 Type of health facility Children Adults Hospital 37.3% 36.5% Health center 62.7% 63.5% Total 100% 100%

Evaluation of Clinical and Immunologic Outcomes from the National ART Program Retention For this evaluation, patients who were dead, lost to follow-up, stopped treatment, or transferred were not considered to be retained 92% of adults and 93% of children remained on ART at their original site at 6 months of therapy 86% of adults and 89% of children remained on ART at their original site at 12 months of therapy

Evaluation of Clinical and Immunologic Outcomes from the National ART Program Mortality Of adults who initiated ART: by 12 months, 4.6% were dead, 5% were lost-to-follow-up, 0.3% had stopped treatment, and 4% had transferred out Of children who initiated ART: by 12 months, 2.6% were dead, 4% were lost-to-follow-up, 4% had transferred out, and none had stopped treatment

Evaluation of Clinical and Immunologic Outcomes from the National ART Program CD4 + Cell Count Change At ART initiation, the median adult CD4 + cell count was 141cells/µL For adult patients with follow-up data, median CD4 + cell counts increased by 98 cells/µL at 6 months and 119 cells/µL at 12 months, suggesting that, on average, adult patients had CD4 + counts of more than 250 cells/µL at 1 year after initiating ART

Evaluation of Clinical and Immunologic Outcomes from the National ART Program CD4 + Cell Count Change For children with follow-up data, median CD4 + cell count changes at 12 months were increases from baseline of: 399 cells/µL for children <24 months old 223 cells/µL for children 2–5 years of age 236 cells/µL for children 6-14 years of age

100% self-reported adherence during 3 and 30 days

Outcome: Self-reported adherence: 30-day recall N=575 N=490 N=352

Timing of missed pills among patients reporting ≤100% adherence in 3 days preceding interview

Most common reasons for ever missing ART

Patient’s level factors predicting self-reported 30-day non-adherence …

Facility level factors predicting self-reported 30-day non-adherence …

Perspectives Decentralisation and integration of HIV services (full coverage) Task shifting: Physician to nurses Nurses to community health workers Reinforce HIV Prevention strategy

Presentation: Results of National Adherence PHE

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Presentation: Results of National Adherence PHE