Care of HIV-Infected Children Reaching the Unreached

Transcription

1 6 th Regional Workshop Awareness of e-health Initiatives and Establishment of Telemedicine Network Ministry of Health & Family Welfare, GOI 14 th & 15 th December 2016 KEM Hospital, Parel, Mumbai Care of HIV-Infected Children Reaching the Unreached

2 Dr. Mamta Manglani Professor & Head, Pediatrics Chief, Div. of Hematology-Oncology, Program Director, Pediatric Centre of Excellence for HIV Care, Lokmanya Tilak Municipal Medical College & General Hospital, Sion, Mumbai, India

3 Pediatric HIV Clinic to Pediatric Centre of Excellence.! Pediatric HIV Clinic established on 1 st Dec 1997

4 Integrated services started in 2003 ART Centre 25 th Aug 2005

5 Regional Pediatric ART Centre November 2006 Pediatric Centre of Excellence for HIV Care 1 st Dec. 2011

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7 Collaborative Project Dr. Sudha Balakrishnan, Ms. IA Kundan, Dr. BB Rewari, Dr. Swapnali Patil, Dr. Tushar Rane, Dr. Maninder Setia, Dr. Khanindra Bhuyan, Dr. Tushar Kotwal, Dr. Prakash Bhoi, Dr. Mukund Diggikar, Dr. Mamatha Lala, Dr. Yashwant Gabhale, Ms. Rohini Sekhar National AIDS Control Organization, GoI Maharashtra State AIDS Control Society, GoM National Health Mission, GoM UNICEF LTMG Hospital, Municipal Corporation of Greater Mumbai

8 MAHARASHTRA 26,809 CLHIVs PLHIVA million 13,913 on Anti Retroviral Treatment (ART) Children million (7%) 2463 children registered in our Pediatric Centre of Excellence for HIV Care (one of the 7 National Centres in the Country) Women million (39%) DACS, Annual Report

9 1008 kms

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11 Aim of Telemedicine To establish link of PCoE with all ART centres for expert opinion through telemedicine on the following: To ensure quality comprehensive care to all CLHIVs in Maharashtra To monitor the care, support & treatment given to CLHIVs all over Maharashtra Pediatric ART initiation, Nutrition and adherence counselling To conduct Tele Reviews periodically for first line failure and Pediatric HIV mortality Capacity building of health personnel

12 What Did We Do? Methodology!

13 Telemedicine Sessions Conducted 15 th October 2013 to 15 th October 2015 (n=599)

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15 Clinical Sessions (n=280) No. of Sessions No. of Beneficiaries Case Discussions Death Reviews Protocol Discussions

16 TRAINING SESSIONS Basic pediatric Counseling Skills Child Palliative Care Counseling

17 Counseling Sessions (n=58) Clinical Counselling No. of Sessions No. of Patients

18 Training Sessions (n=88) No. of Trainings On Site Training Counselling Training CPC Sessions No. of Participants

19 Counseling Training Session in Progress! Telemedicine Counselor conducting the training

20 Review of ART Centres in the State (n=103) Review meetings by State AIDS Control Society held every 3 months A 3 Day Schedule with all participants travelling to Mumbai or other cities Requirement of representatives from each ART Centre (72 centres) Telemedicine a great tool for saving costs of these reviews 103 sessions taken till date with participation by 72 ART Centres

21 District Hospital, Pune

22 Death Reviews Conducted (n=42) CLHIVs, 6 Infants, 36

23 Screening for 2 nd Line ART (n=35) State AIDS Clinical Experts Panel 35 patients reviewed through telemedicine in the study period 10 out of these 35 patients travelled to PCoE, Sion, Mumbai 25 out of 35 were advised through telemedicine and did not need to travel to Mumbai

24 At Follow up VC At First Video Conference

25 Is This Exercise of Telemedicine Useful?

26 Objectives of the Analysis Is Pediatric HIV expert care through telemedicine acceptable to the provider and patient in the domain of Pediatric HIV care and treatment? Does telemedicine improve the quality of Pediatric HIV care? Is it associated with improved outcomes of children on ART/care?

27 Methodology Maharashtra has 72 ART Centres (excluding Mumbai) 35 Linked and 37 Non-Linked ART centres 31 Linked and 28 Non-Linked were functional in the period of analysis (October 2013 to August 2015) Institutional Ethics approval was obtained FGDs and In-depth interviews were conducted Care Providers Care Givers Patients themselves

28 Analysis of the Data Thematic Framework Approach was used to analyse the data NVivo Software was used

29 Results.

30 Anti Retroviral Therapy Centres included in the Analysis Linked with Telemedicne Not linked with Telemedicine

31 Between Oct 2013 and March 2015 in 64 ART Centers in care 4269 children < 18 years 1946 Girls 2319 Boys

32 Enrolled in Care > 18 Years & < 18 Years Boys & Girls < 18 Years 8% 46% 54% 92% > 18 years < 18 years Boys Girls # Enrolled in Care All ages < 18 % < 18 Total % Boys & Girls < 18 Years Enrolled in Care Boys % Girls %

33 Age Distribution < 18 Years Age Distribution < 18 Years 24% 17% 25% 33% 0-4 years 5-9 years years years

34 Pre- ART, ART All < 18 Years % < 18 Years Total % PreART % ART %

35 Children < 18 Years Enrolled in Linked and Non Linked ART Centers # Enrolled in Care (Pre +ART) All ages < 18 Years % < 18 Years Total % Linked ART Center % Non-Linked ART Center %

36 Boys & Girls < 18 Years in Linked & Non Linked ART Centers Boys & Girls <18 in Linked & Non Linked ART Centers Non-Linked Linked 0% 20% 40% 60% 80% 100% Boys Girls

37 ART Outcomes in < 18 Years Linked vs Non Linked ART Centers Alive on ART Significant proportion of < 18 alive in Linked Centers (p <0.001) Significant proportion of < 18 Girls alive in Linked Centers (p <0.05) Loss to Follow up Significantly less proportion of < 18 Lost To Follow Up in Linked Centers (p < 0.007) Significant proportion of year olds alive in Linked Centers (p <0.05)

38 Pre - ART Outcomes in < 18 Years Linked vs Non Linked ART Centers Alive on Pre ART Significant proportion of < 18 alive in Linked Centers (p <0.001) Loss to Follow up No Difference Significant proportion of < 18 Girls alive in Linked Centers (p <0.05) Significant proportion of 5-9 year olds alive in Linked Centers (p <0.05)

39 Quality of Care in < 18 Years Linked vs Non Linked ART Centers (1) Indicator 1: Eligible but not initiated Significantly less proportion of < 18 in the category of Eligible but not initiated in Linked Centers (p <0.001) Significantly less proportion in the category of Eligible but not initiated in Linked Centers o Girls < 18 (p <0.001) o Boys < 18 (p < 0.05) Significantly less proportion of Eligible but not initiated in Linked Centers: o 5-9 years: p <0.05 o years : p < 0.05 o years : p <0.001

40 Quality of Care in < 18 Years Linked vs Non Linked ART Centers (2) Indicator 2: CD4 Missing values Significantly less proportion of < 18 in linked centers had missing Baseline CD4 (p <0.001) Follow up CD4 (p <0.001) Across all age categories, significantly less proportion in linked centers had missing Baseline CD4 (p <0.05 to <0.001) Follow up CD4 (p <0.001) In Boys and Girls significantly less proportion in linked centers had missing Baseline CD4 (p <0.001) Follow up CD4 (p <0.001)

41 Missing CD4 Counts Linked Unlinked 0 Baseline* Latest* * p < 0.05

42 Median CD4 Counts at Baseline in Linked and Non Linked Centers 0 2,000 4,000 6,000 8,000 Non-Linked Linked Linked: 319 (IQR: ) Non-Linked: 311 (IQR: ) P=0.64

43 Median CD4 Counts at Follow up in Linked and Non Linked Centers 0 2,000 4,000 6,000 8,000 Non-Linked Linked: 403 (IQR: ) Non-Linked: 424 ( ) P =0.13 Linked Change between baseline and at follow up : P=0.58

44 Technology Specs Vidyo; license and infra provided by NIC PCoE - National Knowledge Network (100 mbps) ART centers on BSNL ADSL (4 mbps) Encryption at application level possible. EMR/ HIS: Prognosys EMR, NACO HIS Hospital Power back up systems

45 Thank You unite for children