How we refined and refocused programs using a data-driven approach
The appointment of Dr. Deborah Birx as the new Global AIDS Coordinator in May 2014 heralded an enormous change in the PEPFAR world: Within the span of a few weeks, the focus changed from the newly-cemented PEPFAR vocabulary around ‘sustainability’ and ‘country ownership’ to language more targeted at maximizing resources for ‘epidemic control’. As Dr. Birx said at the PEPFAR Annual meeting in Durban in June 2014, “We cannot sustain an uncontrolled epidemic”. Although there has been enormous success in globally scaling up access to HIV testing and counseling (HTC) and anti-retroviral therapy (ART), the point Dr. Birx has continually reiterated in her six months in office, is that we need to find those places and populations in which the epidemic is least-controlled and respond accordingly.
To successfully do this, data is required: Data on locating those who have never been tested and those at highest risk of acquiring HIV, and data that identifies which programs work best at reducing new infections and caring for those already infected. The wide variation in new and existing HIV infections between urban and rural, male and female, and between age groups has long been established; however, the use of this and other data to maximize the entire spectrum of our HIV prevention, care and treatment interventions in a coordinated effort to control the epidemic, has not been maximized. With this challenge ringing in our ears, and a mandate from the Office of the U.S. Global AIDS Coordinator (OGAC) to revise our 2014 annual plan (COP), CDC and the other US Government (USG) agencies utilizing PEPFAR funding in Malawi, sat down to plan how to better work with the Ministry of Health and gain control over the HIV epidemic. As a result of these meetings, the following has been endorsed or adopted.
Malawi has recently endorsed the UNAIDS ‘90-90-90’ goals for 2030, which include:
- 90% of People Living with HIV (PLHIV) are tested and know their status
- 90% of known PLHIV are initiated on Anti-retroviral Therapy (ART)
- 90% of ART patients are retained in care at one year
To reach these ambitious goals we will actively pursue progress by matching the appropriate amount of funding with similar outputs of effort, targeted to the right places and the right populations. The first 90% is the gateway to the subsequent 90’s for the 2030 goals; if we don’t find those already living with HIV, we won’t be able to start them on treatment or keep them in care. To find 90% of people living with HIV (PLHIV), we have to know where to look, and although our national survey data isn’t current, there is enough available information to rethink our overall strategy. Of immediate importance is ensuring we get the highest ‘yield’ for HIV Testing and Counseling (HTC); the highest likelihood of identifying an HIV-positive individual with every test used. This is a recent departure from the last few years in which HTC had become a way to identify those who were negative and provide counseling on staying HIV-negative. Fortunately, thinking has now come full circle, and the role of HIV testing is rapidly regaining its priority as the most important gateway to treatment, survival and epidemic control. This has had the immediate effect of highlighting the importance of testing in health facilities, particularly in settings where HIV prevalence may be higher than the national average, including STI clinics, TB clinics and in-patient wards.
HIV prevention in the new millennium
The emphasis on reaching the 90-90-90 targets mandates that the targeted behaviors for change be HIV testing, accepting treatment, taking one’s medication, and keeping appointments. Should these behavior change and treatment agendas truly align to support each other, the 90’s can be achieved in Malawi. If this happened, then 73% of the approximately one million PLHIV would lower the amount of HIV in their blood so they essentially do not transmit the virus, reducing new infections nationally to 0.2 per 100 individuals per year. This is a staggering 78,000 adult infections and 75,000 pediatric infections prevented in the next five years, a massive impact on HIV prevention in Malawi, the likes of which has never been seen before.
Reviewing our data from a new perspective
Districts in Malawi are made up of anywhere from 100,000 to 1,000,000 people, and HIV prevalence in antenatal (prenatal) clinics within a district can vary from 0.2% to 33%. When reviewing variation in HIV prevalence in the Demographic and Health Survey (DHS) 2010 at the cluster level, it rapidly became clear that the epidemic needs a targeted response at the lowest possible geographic unit, certainly well below the typical approach of district level. All health facilities in Malawi are assigned ‘catchment areas’, an uneven radius around each facility which provides an approximation for the population each health center is responsible for serving. Because the entire population of the country can also be divided into these catchment areas, and because HIV service delivery data is available at the facility level and provides a proxy measure for community coverage, the use of facility and catchment areas to define our refocused response was the most appropriate choice for geographic refining of our programs.
Refining site-level focus
While funding cannot provide support to every ART site in Malawi, our data shows intensive HIV program support isn’t needed in every facility. This has enabled us to rethink how every dollar invested in HIV can produce maximum impact. Several measures for the prioritization of health facilities were considered, and after discussing the pros and cons of each measure with the Ministry of Health Department of HIV and AIDS, we utilized a combination of measures to identify those health facility catchment areas which altogether would provide 90% population coverage based on three priority criteria:
- Number of current ART patients of treatment
- Expected number of HIV-positive pregnancies registering at the ANC clinic
- Number of PLHIV in the health facility catchment area
The last measure was important, as it gives us an estimated program need outside of documented facility services. In each of the measures, we sorted the health facilities in the country in order of size from largest to smallest, and identified which sites would enable us to reach 90% of the population. We then displayed the results visually, via Venn diagram, to show the overlap between the criteria and the health centers.
We found that we could reach 90% of the HIV-positive population by prioritizing support to 50% of the health facilities in the country. The majority of health centers which were to become ‘priority sites’ met two or more criteria, but 99 sites met only one of the three criteria, which emphasizes the importance of knowing priorities when targeting programs for impact.
We now have at hand all of the tools we need to fight the HIV epidemic – and win. We have the program science, the ARVs, trained staff in the health centers, the experience at national, district and site levels, and organizations to support the program in every district in Malawi. And now, we have the data. We’ve mapped out the country’s population, reduced the programs at every site to numbers, and we have a logical approach to moving forward. We have the ability to now intensively target our response within each facility, addressing challenges systematically, and monitoring results. The data is complex and the road ahead still difficult, but for the first time in more than three decades, a clear end to the HIV epidemic is in sight.