Quality of Care, a global perspective :

The future of quality of care

Kevin De Cock,

CDC Kenya

Quality of Care, A Global Perspective: The Future of Quality of Care

Kevin M. De Cock, MD

Country Director,

CDC Kenya

2nd EACS Conference

Brussels, November 16-17, 2016

Division of Global HIV/&TB

CDC Kenya

From Tropical Medicine to Global Health

“People are beginning to

realize that there is nothing in

the world so remote that it

can’t impact you as a person”

William H. Foege

Director, CDC, 1977-1983

Ebola, Zaire 1976

AIDS 1981

IOM Report on EID 1992

“Investing in Health” 1993

World AIDS Conference 1996

WHO Global Action Plan on NCDs 2013

Ebola, West Africa 2014

Paris Climate Change Conference 2015

MDGs World AIDS Conference 2000

PEPFAR SARS 2003

Tropical Medicine, International Health, or Global Health?

State of the Union Address

January 28, 2003

President Bush announces U.S. President’s

Emergency Plan for AIDS Relief

Health Impact: Progress Towards MDGs 4 & 5

Malaria Burden by GNP, and Access to Diagnostics and ACTs, 2015

(WHO, 2016)

Trends in Tuberculosis in the Era of ART

WHO ART Guidelines, 2002

Tuberculosis – standardized therapy,

safe therapy, everywhere….

HIV Science, Policy and Program Convergence

Differentiated Models of Care for ART

“Client-centred approach that simplifies and adapts HIV services across the cascade to

reflect the preferences and expectations of various groups of people living with HIV

(PLHIV) while reducing unnecessary burdens on the health system. By providing

differentiated care the health system can refocus resources to those most in need.”

Chronic liver disease

Cognitive disorders

Non-AIDS cancers

Chronic renal disease

Osteoporosis CVD

Frailty

Depression

Diabetes mellitus

COPD

Leapfrogging

• Cell phones

• E-banking

• Informatics, e-health

• Molecular diagnostics

• Point of care tests

• Vaccines

• Public health approach to ART

Global Health Post-Ebola and the MDGs – Emerging Issues

Universal health

coverage

Non-communicable

diseases

Emerging and re-

emerging infections

Antimicrobial

resistance

Climate change

Injuries

Source: Emerg Infect Dis 2013;19:1192-1197

Silver Linings and Gathering Clouds

Economic growth

Security and conflict

Migration

Corruption

Population growth

Environment and

resources

Climate change

Population Growth and Urbanization

Towards an AIDS-free Generation

“By 2030, end the epidemics of AIDS, tuberculosis, malaria and neglected tropical diseases and combat hepatitis, water-borne diseases and other communicable diseases”

The First “90”

Identification of PLHIV

Source: NACC&NASCOP, 2014 HIV Estimates; PEPFAR Kenya APR 2015 Analysis

0%

1%

2%

3%

4%

5%

6%

7%

8%

9%

10%

11%

12%

13%

14%

15%

16%

Tota

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Ho

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Bay

Siay

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Comparison of Overall and “Remaining Prevalence” after accounting for PLHIV already in care

prevalence

"remaining prevalence"APR15

• 6.5million tests done

• 3%HIV+ yield

HIV+ Yield for Different Testing Approaches

113.291

38.268

17.678 15.041 7.528 5.328 5.124 3.918 1.861 1.398 1.220

2,9%

3,0%

3,5% 4,6%

4,6% 2,5%

17,2%

4,3% 1,6% 2,9% 3,7%

0,0%

2,0%

4,0%

6,0%

8,0%

10,0%

12,0%

14,0%

16,0%

18,0%

20,0%

-

20.000

40.000

60.000

80.000

100.000

120.000

Ou

tpat

ien

t D

ep

artm

en

t

VC

T c

o-l

oca

ted

VC

T s

tan

dal

on

e

Inp

atie

nt

VM

MC

Mo

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Tub

erc

ulo

sis

HIV

Car

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nd

Tre

atm

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t C

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me

-bas

ed

Oth

er

Serv

ice

De

live

ry P

oin

t

Sexu

ally

Tra

nsm

itte

d In

fect

ion

s

HIV Positive Yield

Source: PEPFAR APR 2015 Analysis

• Provider-initiated HIV

testing and

counseling

• Assisted Partner

Services (partner

notification)

• Family testing

• Home-based testing

• Community testing

• Self-testing

Maximizing HIV Testing Yield

The Second “90”

Standard vs. Same-day ART* 100%

92%

71%

50%

100% 100%

80%

61%

0%

20%

40%

60%

80%

100%

120%

Completed CD4 count Initiated ART Alive and in Care at 12months

Alive with undetectableVL

Standard (285) Same Day (Test /Treat)  (279)

Same-day ART initiation was associated with • ART uptake 100% vs 92%, p<0.001

• Improved retention with viral suppression aOR 1.76 (95% CI 1.24-2.49; p=0.002)

• Reduced risk of mortality aOR 0.35 (95% CI 0.14-0.86; p=0.021)

Superior Outcomes with Same-Day HIV Testing

and ART Initiation, Haiti

• *Serena Koenig, et al., GHESKIO, Haiti, AIDS 2016

Treatment Adherence: Recommendations

WHO Guideline Dissemination Workshop, Johannesburg, South Africa, April 25-29, 2016

Effective interventions Peer counsellors

Mobile phone text

messages

Reminder devices

Cognitive behavioural

therapy

Behavioural skills training

/medication adherence

training

Fixed dose combinations

and once daily regimens

Differentiated Models of Care for ART

“Client-centred approach that simplifies and adapts HIV services across the cascade to

reflect the preferences and expectations of various groups of people living with HIV

(PLHIV) while reducing unnecessary burdens on the health system. By providing

differentiated care the health system can refocus resources to those most in need.”

31% 41%

14% 14%

30% 35%

18% 17%

13% 9%

17% 61%

0% 21% 21%

58%

0% 10% 20% 30% 40% 50% 60% 70%

>90 days

31-60 days

>90 days

31-60 days

>90 days

31-60 days

>90 days

31-60 days

5-1

0yr

s2

-5yr

s1

-2yr

s<1

yr

*CHAI Kenya. Cross-sectional Assessment of ART prescription practices, 2016; **PEPFAR Kenya Expenditure Analysis, FY15

Average ART clinic visits, FY15**

• Adults: 4.9 per year

• Peds: 5.1 per year

83%

86%

39%

42%

ART PRESCRIPTION PRACTICES BY DURATION ON TREATMENT*

EVIDENCE OF DIFFERENTIATED CARE MODELS IN KENYA

Rapid ART Refill for Stable Patients Bomu Hospital, Kenya

Clinician assesses for rapid ART refill eligibility

If eligible, refill prescription (3-6 months)

• Triplicate form (pharmacy, file, patient)

• 3 months maximum dispensed

Refill visit:

• 3 months. Reception and direct to pharmacy

• Advised to come to the clinic if become ill.

• If new WHO stage 3/4, rapid refill suspended

Clinic visit:

• Every 6 months, full review, CD4/VL done

• 3-day return visit for lab review

Source: Bomu Medical Center, 2016

Viral suppression: 88%

EVIDENCE OF DIFFERENTIATED CARE MODELS IN KENYA

KENYA MODEL OF DIFFERENTIATED CARE

Care of patients beyond First Year of ART

Care of patients within First Year of ART

Advanced HIV Disease

Stable Patients Unstable Patients

WHO Stage 3 or 4

CD4 count ≤ 200

cell/Μl/ (or ≤ 25% for children ≤ 5 years old)

WHO Stage 1 or 2

CD4 count > 200 cell/μL

(or > 25% for children ≤ 5 years old) Eligible for Community

ART Service delivery as a package of Care Weekly follow-up until ART initiation, and then at week 2 and 4 after ART

initiation, and then monthly for the first 6 months of ART

Those who present well

APPROACH BASED ON DURATION OF ART

CRITERIA FOR A HEALTH FACILITY TO IMPLEMENT A COMMUNITY-BASED ART DISTRIBUTION PROGRAM

Health Information Systems Has a functioning system in place to monitor and report patient-level outcomes

Service Delivery • Uptake of routine VL monitoring is ≥ 90% • Has functional system in place for fast-tracked facility-based ART distribution for stable patients

Commodity Management

• Currently has ≥ 3 months stock of ARV on site • Has capacity (including personnel and supplies) Leadership

Involvement of County Leadership Focal person to oversee distribution Program

Finance To implement and monitor community-based ART distribution

Human Resources

• Appropriate personnel for distributing ART: • Capacity to train and supervise ART

distributors

• Supply chain issues – increased need for ARV supply

• Patient related issues with bulky prescription

Peer educator collecting ARV drugs at AMPATH Clinic. Photo used with permission

OPERATIONAL ISSUES

Adherence support Rapid referral Retention Program evaluation

The Third “90”

Viral Load Testing in Kenya

National Viral Load Testing Labs Rapid scale up of VL Testing:

2015 Jan- Dec: 649,366 (83% viral suppression)

2016 Jan – Aug: 657,610 (84% viral suppression)

Challenges:

Prolonged turnaround time

– Equipment breakdown/downtime

– Commodity stockouts

– HR challenges

– Uneven distribution of workload

Sub-optimal lab-clinical interphase

– Delivery of results to patient files

– Utilization of results by clinicians

Viral suppression by age, SAPR ‘16

61,0 67,0 65,0 61,0

86,0

39,0 33,0 35,0 39,0 14,0

<5 5 to <10 10 to <15 15 to <18 18+

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Age (years)

Su

pp

ressio

n r

ate

s (

% o

f to

tal te

sts

)

Suppressed Not suppressed

Measuring Progress and

Impact

90:90:90 Impact

• Program targets, not

impact measures

• Ratios, not rates

• People can drop out and

re-enter

• Need cohort analysis

• Need electronic medical

records

• Critical impact indicators

are HIV incidence and

death, possibly TB trends

Nairobi Mortuary Study, 2015

“The death rate is a fact,

everything else is an inference”

William Farr, 1807-1883

Measuring the Cycle of HIV