2015 indicator reference guide retained on art at 12 months

Treatment March 2015
ARV Services
Indicator code:
TX_RET
1
Percentage of adults and children known to be alive and on treatment 12 months after
initiation of antiretroviral therapy
Purpose:
This indicator measures the proportion of individuals who have retained on antiretroviral therapy (ART). ART is
viewed by the scientific community and PEPFAR not only as essential for decreasing morbidity and mortality, but
also as a highly effective approach to prevent HIV transmission. Death and loss to follow-up are the two highest
causes of patient attrition from ART, especially in the first few months after initiating on ART. High retention is one
important measure of program success, specifically in reducing morbidity and mortality, and is a proxy for overall
quality of the ART program. Monitoring the program level retention is a critical quality of service indicator at the
site, national and PEPFAR program levels as it can highlight barriers to health seeking behaviors and/or gaps in
access to and provision of health services. This indicator is also important for long term sustainability of the ART
programs.
NGI Mapping: T1.3.D continuing; same indicator with modified disaggregations
PEPFAR Support
Target/Result
Type:
Both Direct Service Delivery (DSD) and Technical Assistance-Service Delivery Improvement
(TA-SDI) - targets and results should be reported to HQ
Numerator:
1
Number of adults and children who are still alive and on treatment at 12 months after
initiating ART
Denominator:
1
Total number of adults and children who initiated ART in the 12 months prior to the
beginning of the reporting period, including those who have died, those who have
stopped ART, and those lost to follow-up.
Disaggregation(s):
1
Age/Sex (disaggregation required for both numerator and denominator):
<5 Male, <5 Female, 5-14 Male, 5-14 Female, 15-19 Male, 15-19 Female, 20+ Male, 20+
Female
1
Pregnant at ART initiation, Breastfeeding at ART initiation (disaggregation
required for both numerator and denominator)
3 Recommended: Retention at 6, 24, 36 months
3 Recommended: Key populations: SW, MSM/TG, PWID
Data Source: Program monitoring tools; ART registers/databases and cohort/group analysis forms.
Data Collection
Frequency:
Data should be collected continuously at the facility level as part of service delivery and
aggregated in time for PEPFAR reporting cycles. Data should be reviewed regularly for the
purposes of program management, to monitor progress towards achieving targets, and to
identify and correct any data quality issues.
Method of Measurement:
Explanation of Numerator: The numerator requires that adult and pediatric patients must be alive and on ART at 12
months following their initiation of treatment.
For a comprehensive understanding of survival, the following data must be collected:
 Number of adults and children in the ART start-up groups initiating ART at 12 months prior to the end of the
reporting period (denominator)
 Number of adults and children still alive and on ART at 12 months after initiating treatment (numerator)
The reporting period is defined as a continuous 12-month period that has ended within a pre-defined number of

months from the submission of the report. The pre-defined number of months can be determined by PEPFAR or
national reporting requirements. If the PEPFAR reporting period is 1 October 2014 to 30 September 2015,
countries will calculate this indicator by using all patients who started ART any time during the 12-month period
from 1 October 2013 to 30 September 2014. A 12-month outcome is defined as the outcome, i.e., whether the
patient is still alive and on ART, dead or lost to follow-up, 12 months after starting. For example, patients who
started ART during August 2014 will have reached their 12-month outcomes in August 2015 (e.g., August 4th 2014-
August 3rd 2015). Patients who started ART during January 2014 will have reached their 12-month outcomes in
January 2015.
The numerator does not require patients to have been on ART continuously for the 12-month period. Patients may
be included in the numerator (and denominator) if they have missed an appointment or drug pick-up or
temporarily stopped treatment during the 12 months since initiating treatment, as long as they are recorded as still
being on treatment at month 12.
For example, a patient who started ART in September 2014 would be considered “alive and on ART at 12 months”
(in September 2015) if:
 The patient visited the facility and received ARVs in September 2015; OR
 The patient had enough ARVs to last through the end of September 2015 (month 12) based on the last drug
pick-up (e.g., patient received 60 days of drug on August 15th, or patient received 30 days of drug on September
1st, etc.).
However, the patient would NOT be considered “alive and on ART at 12 months” if:
 The patient did NOT have enough ARVs to last through the end of September 2015 (e.g., patient received 30
days of drug on August 1st); AND
 The patient was dead, transferred out, stopped, or lost to follow-up at the end of September 2015.
At the facility level, patients who have transferred in with a known treatment initiation date that falls within the
reporting period should be counted. Conversely, patients who transferred out of the facility should not be counted
in that facility’s cohort. See “Explanation of Net Current Cohort” in the “Interpretation” section below for further
details.
For those patients who started ART in September 2014, if at any point during the period September 2014 to
September 2015 these patients die, are lost to follow-up (and do not return), or stop treatment (and do not restart),
then at month 12 (September 2015), they are NOT on ART, and NOT included in the retention numerator.
Conversely, a patient who started ART in September 2014 and who missed an appointment in December 2014, but
is recorded as on ART in September 2015 (at month 12) is on ART and will be included in the numerator. The
number of adults and children on ART at 12 months includes patients who have transferred in (and their initiation
date is known) at any point from initiation of treatment to the end of the 12-month period and excludes patients
who have transferred out during this same period to reflect the net current cohort at each facility. What is
important is that the patient who has started ART in September in 2014 is recorded as being alive and on ART 12
months after initiation, regardless of what happens after that initiation date within the reporting period of interest
(i.e., for this example, 1 October 2014 to 30 September 2015).
Explanation of Denominator: The denominator is the total number of adults and children in the (monthly) ART
start-up groups who initiated ART at a point 12 months prior to the beginning of the reporting period, regardless of
their 12-month outcome. (i.e., died, LTFU, stopped); this includes those “New” on ART as well as those who
“Transferred In” if they have a cohort-start date within the reporting period of interest. At the facility level, the
Transfers Out (TO) will be taken out of the denominator as well as the numerator. It is assumed that if a patient

transfers out from an ART facility, that patient will be a “transfer in” at a new ART facility. Logically, facilities and
programs may visualize this calculation of the denominator as the facility or program is no longer responsible for
an ART patient who has officially transferred out to another ART facility.
For example, for the reporting period October 1, 2014 to September 30, 2015, this will include all patients who
started ART during the 12-month period from October 1, 2013 to September 30, 2014. This includes all patients,
both those on ART as well as those who are dead, have stopped treatment or are lost to follow-up at month 12.
Again the denominator includes patients that have transferred in (and their initiation date is known) and excludes
patients that transferred out during the time period.
This indicator should NOT be estimated. This indicator should be calculated directly from information gathered in
standard cohort ART registers or tabular analysis from electronic patient level databases.
Country teams should ensure that all sites are reporting on the same 12 ART start-up groups. Only sites that have
been operational for at least 24 months prior to the end of the reporting period should report, so that all sites
report on the same 12 ART start-up groups. PEPFAR country teams may use the USG FY reporting period as the
timeframe for the 12 ART start-up groups. Teams may also wish to ‘lag’ by 1-3 months the cohort-months
comprising the annual cohort, in order to allow sufficient time for reporting from data sources (i.e., implementing
partners and/or national systems).
Country teams should record how many ART sites are reporting on this indicator and seek to ensure reporting
among all eligible ART sites (i.e., operational for 24 months) by the end of FY 2015.
Sites are encouraged to disaggregate retention by health status at initiation (e.g., CD4 count or WHO stage), to
review the retention of every ART start up group on a continuous basis, to summarize the data at regular intervals
(e.g., monthly), and to use this information to improve follow-up and retention of patients.
Explanation of Numerator:
The numerator requires that adult and pediatric patients must be alive and on ART at 12 months after their
initiation of treatment.
Explanation of Denominator:
The denominator is the total number of adults and children in the (monthly) ART start-up groups who initiated
ART at a point 12 months prior to the beginning of the reporting period, regardless of their 12-month outcome. (i.e.,
died, LTFU, stopped); this includes those “New” on ART as well as those who “Transferred In” if they have a cohort-
start date within the reporting period of interest.
Interpretation:
At the national level, the number of transferred-in patients should match the number of transferred-out patients.
Therefore, the net current cohort (the patients whose outcomes the facility is currently responsible for recording—
the number of patients in the start-up group plus any transfers in, minus any transfers out) at 12 months should
equal the number in the start-up cohort group 12 months prior.
Using this denominator may underestimate true “survival”, since a proportion of those lost to follow-up are alive.
The number of people alive and on ART (i.e., people retained on ART) in a treatment cohort is captured here. WHO
recommends a target of at least 75% of adults and children alive and on ART at 6 months of follow-up.
Priority reporting is for aggregate survival reporting. If comprehensive cohort patient registries are available then

it is encouraged for countries to track survival at 6, 24, and 36 months. If at 6 months of therapy, the retention rate
is lower than 75%, this information along with other data gleaned can be used to identify areas of adult and
pediatric care that require strengthening and increased attention. In addition, this will enable comparison over
time of survival on ART. As it stands, it is possible to identify whether survival at 12 months increases or decreases
over time. However, it is not possible to attribute cause to these changes. For example, if survival at 12 months
increases over time, this may reflect an improvement in care and treatment practices or earlier initiation of ART.
Therefore, collection and reporting of survival over longer durations of treatment outcomes may provide a better
picture of the long-term success of ART.
PEPFAR Support:
DSD: Individuals will be counted as receiving direct service delivery support from PEPFAR when BOTH of
the below conditions are met: Provision of key staff or commodities AND frequent, at least quarterly,
support to improve the quality of services.
TA-SDI: Individuals will be counted as supported through TA-SDI when the point of service delivery
receives support from PEPFAR that meets the second criterion only: Frequent, at least quarterly support to
improve the quality of services.
1. PEPFAR is directly interacting with the patient or beneficiary in response to their health (physical,
psychological, etc.) care needs by providing key staff and/or essential commodities for routine service
delivery. For PLHIV receiving ART, this can include ongoing procurement of critical commodities, such as
ARVs, or funding for salaries of HCW who deliver HIV treatment services. Staff who are responsible for the
completeness and quality of routine patient records (paper or electronic) can be counted here; however,
staff who exclusively fulfill MOH and donor reporting requirements cannot be counted.
AND/OR
2. PEPFAR provides an established presence at and/or routinized, frequent (at least quarterly) support to
those services at the point of service delivery. For ART services, this ongoing support for service delivery
improvement can include: clinical mentoring and supportive supervision of staff at HIV sites providing ART,
support for quality improvement activities, patient tracking system support, routine support of ART M&E
and reporting, commodities consumption forecasting and supply management.
Additional References:
 Three interlinked patient monitoring systems for HIV care/ART, MCH/PMTCT (including malaria prevention
during pregnancy), and TB/HIV: standardized minimum data set and illustrative tools. World Health
Organization 2012 Revision. (http://www.who.int/hiv/pub/me/patient_monitoring_systems/en/)
 4.2, Global AIDS Response Progress Reporting 2013. Construction of Core Indicators for monitoring the 2011
UN Political Declaration on HIV/AIDS. January 2013.
(http://data.unaids.org/pub/Manual/2007/20070411_ungass_core_indicators_manual_en.pdf)
 HIV impact indicator (HIV-I6), The Global Fund to Fight AIDS, Tuberculosis and Malaria Monitoring and
Evaluation Toolkit: HIV, Tuberculosis and Malaria and Health Systems Strengthening Part 2: HIV, Fourth
Edition, November 2011.
(http://www.theglobalfund.org/documents/monitoring_evaluation/ME_Part2HIV_Toolkit_en/)
 WHO updated HIV Drug Resistance Early Warning Indicators and targets – 2012.
(http://www.who.int/hiv/pub/meetingreports/ewi_meeting_report/en/index.html).
 Refer to the PEPFAR Adult Treatment TWG with further inquiries

2015 indicator reference guide retained on art at 12 months

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2015 indicator reference guide retained on art at 12 months