Case Based Surveillance System in Ethiopia

Case Based Surveillance System in Ethiopia

Acronyms POC- Proof of Concept EPHI Ethiopian Public Health Institute FMOH Federal Ministry of Health Ethiopia NASTAD -

Outline Proof of Concept (POC) for implementation of HIV CBS Goal of POC Methods Results Limitations Way forward Current plan

Why POC CDC, FMOH, and EPHI recommend determining feasibility of CBS via Proof of Concept (POC) assessment Ethical approval granted from EPHI and CDC Proof of Concept conducted in Addis Ababa EPHI lead the initiative, NASTAD and CDC provide technical assistance

CBS vs. PMS Case Based Surveillance Individual case data Population level information Describes disease trends Patient demographic and risk information available for all cases Patient Monitoring System Aggregate data Service level information Measures service uptake and performance May provide some demographic and risk information

Goal of POC Goal: Assess existing data and collection processes to define whether criteria are in place to support implementation HIV case based surveillance Objectives Assess quality of surveillance-related variables Identify method to match and link patient data Identify method to improve availability of surveillance-related variables via case reporting Demonstrate patient-level data analyses useful to document patient linkages, disease progression and clinical outcomes

Methods Sample Strategy Adult and pediatric HIV patients Selected Addis Ababa health facilities Point in time assessment of ART clinical data Table: Health facilities participating in Proof of Concept for HIV Case Based Surveillance, Addis Ababa, Ethiopia, 2014-2016 Data Quality Assessment Case Matching Case Reporting Data Analysis Paper Elect. Elect. Paper Elect. Facilities 24 21 34 10 34 Records 1500 52817 108138 96 108138

Results by Objective

1. Quality Assessment Paper Variable Name Percent Complete & Valid Variable Name Percent Complete & Valid Year of death 23.3 Name of institution referred to 83.0 Month of death 23.3 Patient grandfather name 86.2 Year of ART regime change 26.1 Syphilis test result 86.4 Patient expected delivery month (if pregnant) 29.5 Patient cell phone number 86.7 Patient expected delivery year (if pregnant) 30.5 Month of referral to treatment and care 86.8 Year of infant PCR 36.8 Year of referral to treatment and care 86.8 Day postnatal ART prophylaxis given 37.3 Name of diagnosing institution 86.9 Month of infant PCR 37.4 Patient Kebele of residence 87.2 Month postnatal ART prophylaxis given 38.2 Year of HIV diagnosis 87.8 Year postnatal ART prophylaxis given 38.4 CD4 value 89.0 Mother treated at delivery 38.8 Year of CD4 test 89.0 Month of ART regime change 41.4 Patient father name 90.0 Day of infant PCR 41.5 Month of CD4 test 90.0 Patient mother's name (for exposed infant) 50.8 MRN 90.5 Patient pregnancy status (if female) 57.9 Patient name 90.6 Year of delivery 58.6 Why eligibly for ART 94.9 Infant treated at delivery 58.7 Month of HIV diagnosis 96.4 Month of delivery 65.5 Day Patient Last Visit 96.4 Day of delivery 67.2 Month Patient Last Visit 96.6 Partner tested 68.8 Year Patient Last Visit 96.6 Unique ART number 71.6 Year of HIV care medical visit 97.2 Patient mother's code (for exposed infant) 72.2 ART regime 97.6 Year cotrimoxazole prescribed 79.1 WHO clinical staging 97.6 Year of first ART prescription 79.2 Patient sex 97.6 Month of first ART prescription 79.8 Month of HIV care medical visit 98.4 Month cotrimoxazole prescribed 79.9 Patient age 98.7 Patient Woreda of residence 80.9

1. Quality Assessment Electronic Variable Name Percent Complete Variable Name Percent Complete Variable Name Percent Complete Address Region 0.0% Status 27.8% Estimated delivery date Western 59.2% ANC Register Number 0.0% CD4Percent Child 30.7% Estimated delivery day 59.4% Age Mo 0.9% Last Visit TB Screen 34.2% Estimated delivery year 59.4% Height 1.0% WHO stage 3 date Western 34.7% Estimated delivery Month 59.6% Height Adult 5.2% WHO stage 3 month 34.7% Last Visit Date Western 60.0% WHO stage 4 date Western 6.2% WHO stage 3 day 34.7% Last Visit Day 60.1% WHO stage 4 day 6.2% WHO stage 3 year 34.8% Last Visit Month 60.1% WHO stage 4 month 6.2% Appoint Date Western 41.2% Last Visit Year 60.1% WHO stage 4 year 6.2% Appoint Month 41.2% Referral Information 84.1% TI From Where 7.4% Appoint Day 41.2% Address Kilfe Ketema 93.9% Last Visit CTX Adherence 9.0% Appoint Year 41.2% Pregnant during enrollment 94.9% Address Woreda 11.7% Last Visit Weight 44.6% Chronic Date Western 98.1% DOB Date Western 14.6% Weight 52.1% HIV Test Day Western 99.6% DOB Month 14.7% CD4Count Adult 53.0% HIV Treatment History Day 99.7% DOB Day 14.8% Functional Status 53.6% HIV Treatment History Month 99.7% DOB Year 15.0% WHO Stage 54.5% HIV Treatment History Year 99.7% Status Date Western 17.0% Eligible Ready Date Western 54.6% Chronic Day 100.0% Status Year 17.0% Eligible Ready Year 54.6% Chronic Month 100.0% Status Day 17.0% Med Eligible Date Western 54.6% Chronic Year 100.0% Status Month 17.0% Med Eligible Year 54.6% Reason medically eligible for ART 100.0% Devtal Milestone 19.2% Eligible Ready Day 54.6% CRDID 100.0% WHO stage 2 date Western 22.9% Eligible Ready Month 54.6% Age 100.0% WHO stage 2 year 22.9% Med Eligible Day 54.6% Gender 100.0% WHO stage 2 month 22.9% Med Eligible Month 54.6% Age Yr 100.0% WHO stage 2 day 22.9% Original Regimen 54.8% WHO stage 1 date Western 25.0% ART Start Year 54.8% WHO stage 1 year 25.0% ART Start Date Western 54.8% WHO stage 1 month 25.0% ART Start Day 54.8% WHO stage 1 day 25.0% ART Start Month 54.8%

2. Linking patient data Figure: Identification of unique HIV patients in electronic medical records via application of match algorithms 34 health facilities, Addis Ababa, Ethiopia, June 2015 March 2016 Match Algorithm Records Automated match Manual review Manual match No. % No. % No. % Exact 7220 6.7 1449 20.1 1387 95.7 mexact 2688 2.5 2688 100.0 1561 58.1 PUID 6846 6.3 6846 100.0 1882 27.5 mpuid 7053 6.5 7053 100.0 703 10.0

2. Linking patient data Figure: Identification of unique HIV patients in electronic medical records via application of matching algorithms 34 health facilities, Addis Ababa, Ethiopia, June 2015 March 2016 108,138 records Exact 7,220 records mexact 2,688 records PUID 6,846 records mpuid 7,053 records 103,324 unique patients 956 (0.9%) unique patients received care in 1 or more (range 2-6) health facilities

Percentage 3. Quality improvement and case reporting 35.0 Reported HIV cases by age group (n=88), 10 health facilities, Addis Ababa February March, 2016 30.0 29.2 25.0 20.0 18.0 15.0 14.6 11.2 10.0 7.9 6.7 9.0 5.0 2.2 1.1 0.0 0-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50+ Age Groups

3. Quality improvement and case reporting Percentage of HIV case patients (n=96) with complete data by variable, Addis Ababa -- February - March, 2016 Active case reporting Retrospective case reports 100% 80% 60% 40% 20% 0%

4. Patient descriptive analyses by residence HIV unique patients by patient residence, 33 health facilities, Addis Ababa, Ethiopia Addis Ababa Afar Amhara Benshangul Dire Dawa Gambela Harar Oromia Other SNNPR Somalia Tigray Region Addis Ababa Afar Amhara Benshan gul Dire Dawa Gambela Harar Oromia Other SNNPR Somalia Tigray No. 90876 19 319 24 17 23 21 1806 5728 80 11 107

Count HIV Treatment Cascade All Patients 120000 Patients (n=103324) engaged in HIV treatment and care, Proof of Concept for HIV Case Based Surveillance, 34 health facilities, Addis Ababa, Ethiopia, 1996-2014 100000 102822 80000 60000 67619 60344 60321 40000 65.8% 89.2% 100% 20000 0 Diagnosed, registered at HIV Treatment Clinic Linked to Care Eligible for ART Started ART

Count HIV Treatment Cascade Adults >=15 years 120000 Adult patients (n=99181) engaged in HIV treatment and care, Proof of Concept for HIV Case Based Surveillance, 34 health facilities, Addis Ababa, Ethiopia, 1996-2014 100000 98727 80000 60000 65247 57972 57949 40000 66.1% 88.9% 100% 20000 0 Diagnosed, registered at HIV Treatment Clinic Linked to Care Eligible for ART Started ART

Count HIV Treatment Cascade Pediatrics <15 years Pediatric patients (n=4143) engaged in HIV treatment and care, Proof of Concept for HIV Case Based Surveillance, 34 health facilities, Addis Ababa, Ethiopia, 1996-2014 4500 4000 4095 3500 3000 2500 2372 2372 2372 2000 1500 1000 57.9% 100% 100% 500 0 Diagnosed, registered at HIV Treatment Clinic Linked to Care Eligible for ART Started ART

Count HIV Treatment Cascade Pregnant Females Pregnant female patients (n=4576) engaged in HIV treatment and care, Proof of Concept for HIV Case Based Surveillance, 34 health facilities, Addis Ababa, Ethiopia, 1996-2014 5000 4500 4568 4000 3500 3000 2500 2000 1500 1000 500 2291 1663 1662 50.2% 72.6% 99.9% 0 Diagnosed, registered at HIV Treatment Clinic Linked to Care Eligible for ART Started ART

Count HIV Treatment Cascade Tuberculosis Co-infection Tuberculosis co-infected patients (n=4818) engaged in HIV treatment and care, Proof of Concept for HIV Case Based Surveillance, 34 health facilities, Addis Ababa, Ethiopia, 1996-2014 5000 4752 4500 4000 3500 3000 2741 2741 2739 2500 2000 1500 57.7% 100% 99.9% 1000 500 0 Diagnosed, registered at HIV Treatment Clinic Linked to Care Eligible for ART Started ART

Limitations Quality assessment data sources different Results not directly comparable; provides information on two primary sources of HIV surveillance data Quality of key variables less than anticipated Case matching algorithms affected by quality of key variables Longitudinal analysis limited by point in time dataset Sample of health facilities in Addis may underestimate patient duplication/mobility across health system

FMOH View on proof of Concept The result of the POC reviewed by the TWG and FMOH The ministry endorsed a larger scale implementation of the program under the leadership of EPHI

Way Forward Implement routine electronic data transfer and case reporting Establish system requirements Data elements Standard format Enable central database to receive, validate, transform, store, and analyze data Phased approach of on-boarding health facilities for reporting Diagnosed cases Key sentinel events on diagnosed cases Create mechanisms/pathways for data transfer All electronic Electronic/paper mix All paper

Based on POC- HIV case Based surveillance protocol developed and submitted for review Objectives of Ethiopia CBS protocol Define, gather requirements, and implement the Ethiopia HIV case based surveillance Implement routine case reporting, data transfer, and centralized data management of HIV case based surveillance system Monitor implementation and scale up of HIV case reporting

Methods Population to be studied All individuals who are diagnosed with HIV and/or receiving HIV health services at participating health facilities and their associated community based service centers Selection criteria and proposed sites Volume of HIV-positive tests and HIV patients on care and treatment Availability of EMR systems and technical capacity to perform secure data transfer Region 2017-2018 2018-2019 2019-2020 Total Addis Ababa 48 100 112 260 Oromia 52 71 -- 123 Dire Dawa -- 37 -- 37 Amhara -- 100 14 114 Tigray -- 35 -- 35 Total 100 (17.6%) 343 (60.3%) 126 (22.1%) 569 (100%)

Data Sources HCT (VCT and PITC) VERA Client Referral Form HIV Pharmacy Records HIV CBS Data Sources PMTCT Register EMR system Laboratory Information Systems ART Register

Indicators Knowing status Linkage to care Late diagnosis Average time for ART initiation Started ART Currently on ART ART retention VL supression AIDS death CBS implementation will generate information to monitor the three 90 for the country

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