Download Challenges in monitoring ARV therapy

Challenges in monitoring
ARV therapy
A clinical and public health view
of the issues involved
Charlie Gilks
SRM team, HIV department
The M&E Pipeline
MONITORING
EVALUATION
Process Evaluation
Effectiveness Evaluation
INPUTS PROCESS OUTPUTS OUTCOMES IMPACT
Core problem for ART
Programmes
ART does not easily fit into M&E pipeline
•
•
•
•
The only easy parts to define are the inputs
Process is complex and open-ended
Outputs differ according to the processes
Outcome and Impact (the goals of therapy) are
varied and have not been agreed upon
Quality not just quantity - numbers on ART
Processes and Outputs
• ART turns HIV into a chronic disease process
- open-ended, continuous therapy with lifelong care
- in life, healthy people/healthier patients move around
- long-term adherence matters
• ART and the simplified Public Health approach
- different treatments: first line and second line
- toxicity means some drugs have to change
- many patients will end up failing treatments
Outcomes and Impact
Several different measures of “effectiveness”
–
–
–
–
improved survival / mortality rates
quality of life
reduction in HIV transmission
drug resistance contained
Which should programmes be evaluated on?
How will this be decided?
This critically impacts the M&E process
Developing process indicators
Key is to simplify clinical decision making process
Then standardise indicators around this
Charlie’s four S’s - the core of ARV management:
–
–
–
–
Start according to guidelines on first-line ART
Substitute single drug for toxicity
Switch for failure to second-line ART
Stop and move to palliative care
sadly, this only works in english …. but the principle are the same
Addressing the Process Issues
The key is matching up different system flows
patients on treatment
drug supplies
money (fee for service)
All intersect at the point of dispensing ARVs
Different components with this linkage
What are the components - 1
Patient identifier: mobility and life-long care
– unique
– non-transferable
– robust
Drug supply: link ordering to use
– tracking stock to and in pharmacy
– dispensing/prescribing log
– avoid stock-outs, expiry on shelf and pilfering
What are the components - 2
• Patient records and forms: progress and Px
– facility-based: clinical notes, patient registers
– patient-held: treatment card
• Data collection system: new or integrated
– data to central monitoring points
– data transfer in timely fashion
(warehouse, MoH, M&E unit, budget centres)
Current approaches
Most projects use paper records (as does TB)
Complex, non-standardised data collection
Grave disadvantages with paper:
–
–
–
–
slow
inaccurate
insecure
labour-intensive
Paper may work in single facility but not robust
enough to go to scale, or for national reporting
What can technology offer ?
•
•
•
•
Unique patient identifier - fingerprints
bar-coding of drug cartons
smart cards (clinic data and prescriptions)
simple smart card readers
– treatment centres
– dispensing centres
• mobile telephone-based linkages
The “Luddite” view
Sceptics abound when technology is discussed
•
•
•
•
too fragile for developing countries
too complex for public sector to organise
too costly
staff not competent or skilled enough to use
There is no other way to monitor ART to scale
This is a unique opportunity to fast-tract change
Some conclusions
M&E of ART is complex and challenging
Need for consensus on goals of treatment
Processes can be simplified (around the 4S’s)
Standardised indicators can be developed
Facility-based paper records inadequate for task
“Technology” can and will have to be utilised