Indicators manual
- 1. Republic of Kenya Ministry of Health Antiretroviral Drug Therapy in Kenya The ART/HMIS Training Materials (Indicators Manual) National AIDS and STI Control Programme (NASCOP) August 2006
- 2. Table of Contents 1 Percentage contribution of patients enrolled for Comprehensive HIV care by entry point. 1 1.1 Percentage entering through PMTCT........................................................................... 1 1.2 Percentage entering through VCT ................................................................................ 1 1.3 Percentage entering through TB outpatient.................................................................. 1 1.4 Percentage entering through In-patient ........................................................................ 1 1.5 Percentage entering through CWC............................................................................... 1 1.6 Percentage entering through All Other sources............................................................ 2 2 Percentage of positive referred patients from VCT who register for comprehensive HIV care. ...................................................................................................................................... 3 3 Number of persons enrolled and eligible for ARVs but not yet started. .............................. 4 4 Number of new patients starting ARVs within the period by WHO stage. ......................... 5 5 Cumulative number of persons ever started on ARVs at this facility at the end of this period.................................................................................................................................... 5 6 Total number of patients currently on ARVs. ...................................................................... 6 7 Total number of patients currently on post exposure prophylaxis (PEP)............................. 7 8 Total number of patients currently on prophylaxis. ............................................................. 8 9 Percentage of cohort patients alive and on ART after 6, 12 and 24 months ........................ 8 9.1 Percentage of patients alive and on ART after 6 months ............................................. 9 9.2 Percentage of patients alive and on ART after 12 months ........................................... 9 9.3 Percentage of patients alive and on ART after 24 months ........................................... 9 10 Proportion of patients still on 1st line ART 12 months after initiating ART................... 9 11 Proportion of patients still on ORIGINAL 1st line regimen 12 months after initiating ART. ............................................................................................................................... 10 12 Proportion of patients who have SUBSTITUTED to an alternative 1st line regimen after 12 months of initiating therapy. ............................................................................. 11 13 Proportion of patients who have SWITCHED to a 2nd line (or higher) regimen after 12 months of initiating therapy. .......................................................................................... 11
- 3. 1 PERCENTAGE CONTRIBUTION OF PATIENTS ENROLLED FOR COMPREHENSIVE HIV CARE BY ENTRY POINT. Goal: To identify the relative contribution of different entry points to the Comprehensive HIV Care programme in order to be able to adjust awareness activities and case finding at the different service delivery levels. Definition of Indicator This is a distribution of all patients entering Comprehensive HIV care according to source of referral. This indicator is broken down into six sub indicators. 1.1 Percentage entering through PMTCT Numerator: Total number entering through PMTCT Denominator: Total enrolled 1.2 Percentage entering through VCT Numerator: Total number entering through VCT Denominator: Total enrolled 1.3 Percentage entering through TB outpatient Numerator: Total number entering through TB outpatient Denominator: Total enrolled 1.4 Percentage entering through In-patient Numerator: Total number entering through In-patient Denominator: Total enrolled 1.5 Percentage entering through CWC Numerator: Total number entering through CWC Denominator: Total enrolled ART/HMIS Materials – Indicators Manual 1
- 4. 1.6 Percentage entering through All Other sources Numerator: Total number entering through All Other sources Denominator: Total enrolled Interpretation Patients entering Comprehensive HIV Care will be enrolled from VCT, PMTCT, CWC, TB, In-patient wards and other sources. If a larger proportion of patients is from sources such as Blood Bank, this may imply that patients who are bedridden and are at risk of losing their lives are not accessing the ARVS as they should. In the initial phase of the program, we expect to enrol more people from the wards and home-based care centres. This situation however, may change over time. Note: Further analysis can be done by gender and/or age to show the recruitment by age and gender. Response If it is discovered that there is consistently a high proportion enrolling via a single source, then counselling and referral services may need to be strengthened in the other sources. Analysis Guidelines Quarterly: Each facility team should look at the indicator to determine where to take action. The district level can do an analysis of distribution of client sources and investigate the reasons behind such a situation. Data Sources: Monthly Summary Sheet; column ID (a) Numerator: Number enrolled through an individual entry point, e.g., PMTCT, VCT, TB Patients, In Patients, CWC, and All Others Denominator: Total enrolled in the reporting period. ART/HMIS Materials – Indicators Manual 2
- 5. 2 PERCENTAGE OF POSITIVE REFERRED PATIENTS FROM VCT WHO REGISTER FOR COMPREHENSIVE HIV CARE. Goal: To ensure that all patients tested positive are informed and offered comprehensive HIV care services when they enrol for HIV care. It is used to measure effectiveness of counseling and testing services as entry point for comprehensive HIV care services. Definition of Indicator These are patients referred from VCT for comprehensive HIV Care Services, after testing positive. It is desired that all patients referred register for comprehensive Care services. Numerator: Total Number of patients enrolled into comprehensive Care through VCT Denominator: Total number of Positive patients referred from VCT centers for Comprehensive Care in the district. Interpretation Every patient referred for comprehensive HIV Care must access the service. Loss of patients between VCT and comprehensive HIV Care services signifies a problem. Response The district should identify which VCT centers are losing patients and identify reasons. These may include long distances, acceptability of comprehensive HIV care service or inadequate post-test counselling. For more details on improving quality of counselling services, please refer to the appropriate guidelines on VCT. Analysis Guidelines At district level, this indicator should be analyzed quarterly looking at the contributions to the Comprehensive Care clinic from all the VCT centers. This includes identifying institutions with higher dropout rates between themselves and comprehensive HIV care services. Data Sources: Monthly Summary Sheet, column ID (a); VCT row. ART/HMIS Materials – Indicators Manual 3
- 6. 3 NUMBER OF PERSONS ENROLLED AND ELIGIBLE FOR ARVS BUT NOT YET STARTED. Goal: To get the insight of reasons for delaying starting ART of those who would medically qualify to start ART Definition of Indicator This is a number of patients enrolled in comprehensive HIV care who are medically eligible for ARVs but not started on ARVs during the period under review. Calculation of Indicator: Total medically eligible minus Total enrolled on ART during the same period. Interpretation Medical eligible is only 1 of the used criteria/conditions to assess a person’s readiness to start ART (adherence will depend of many other factors and likeliness of good adherence is another major criteria/condition) – somebody has to be ready to be enrolled on ARV and this might take more time say days or weeks. Usually, this shouldn’t be a problem as starting ARV treatment should ideally allow some flexibility (in most cases, it should not be started in emergency conditions and not as main treatment). Response If at the end of the period, there are still some patients who were medically eligible for ART but not commenced on ART, this must be investigated and corrective measures instituted. Potential problems may include: insufficient drugs, inability to pay, suspect adherence problems or other delays in the system. Note: Record reviews can help to identify the problems. Analysis Guidelines This indicator is used with indicator 7.1.and 7.3 It should be analyzed quarterly at facility, District, Provincial and National level. Data Sources: Monthly Summary Sheet, column (f) Calculation of indicator: Total medically eligible minus total enrolled on ART during the same period. ART/HMIS Materials – Indicators Manual 4
- 7. 4 NUMBER OF NEW PATIENTS STARTING ARVS WITHIN THE PERIOD BY WHO STAGE. Goal: To monitor the stages of the disease at which patients are accessing ARVs so as to ensure that more people with advanced disease are given priority. Definition of Indicator This is the number of patients according to WHO stages, broken down by gender and age, who are enrolled into ART during the reporting period. Numerator: Number of patients commenced on the first line drug regimens in this facility, distributed by WHO Stage, gender and age. Interpretation Regardless of age and gender, it is expected that as many patients as possible access ART services, with more emphasis placed on those in advanced stages of the disease. Response If the distribution of patients starting ART is very different from the general distribution of HIV/AIDS and pre-ART data, further investigation must be instituted. The actual monthly enrolments should always be compared to the expected monthly enrolments. This indicator can be analysed in conjunction with indicator #1. Analysis Guidelines This should be analyzed quarterly and annually at facility, district, provincial and national level. Data Sources: Monthly Summary Sheet, column ID (c) 5 CUMULATIVE NUMBER OF PERSONS EVER STARTED ON ARVS AT THIS FACILITY AT THE END OF THIS PERIOD. Goal: To count individuals who have ever been started on antiretroviral therapy at a service outlet in order to measure progress towards the target. Definition of Indicator This is the total number of patients broken down by gender and age who have ever been started on antiretroviral therapy at this facility (from this period and before), regardless of outcome. ART/HMIS Materials – Indicators Manual 5
- 8. Numerator: Total number of patients ever started on antiretroviral therapy at this facility, distributed by gender and age. Interpretation As the ART programme matures, it becomes imperative that at country and subcountry levels, the level of progress towards set targets is measured. The speed at which the programme is moving towards its target can be measured through periodic increments as a proportion of the set goal. Response If the number of patients ever started on ART falls far short of the target it is most likely that the target was either wrongly set or the programme is not attracting as many patients as it should. In conjunction with indicator # 4 as this may be as a result of the backlog. Analysis Guidelines This should be analyzed quarterly and annually at facility, district, provincial and national level. Data Source: Monthly Summary Sheet, column ID (d). 6 TOTAL NUMBER OF PATIENTS CURRENTLY ON ARVS. Goal: To monitor the number of active patients receiving antiretroviral therapy at the facility at the end of the reporting period. Definition of Indicator This is the number of active patients broken down by gender and age who received ARVs during the reporting period. Numerator: Total number of patients who received ARVs at this facility, distributed by gender and age during the reporting period. Interpretation The indicator monitors the client load during the reporting period. However, it should not include those who died, dropped out, transferred out or lost to follow-up as this overestimates the true number of clients at the end of the reporting period. Response The indicator can be used to measure the client load during the reporting period and prepare drug consumption estimates. ART/HMIS Materials – Indicators Manual 6
- 9. Analysis Guidelines This should be analyzed quarterly and annually at facility, district, provincial and national level. Data Source: Monthly Summary Sheet, column ID (e) 7 TOTAL NUMBER OF PATIENTS CURRENTLY ON POST EXPOSURE PROPHYLAXIS (PEP). Goal: To monitor the number of clients receiving post exposure prophylaxis at the facility at the end of the reporting period. Definition of Indicator This is the number of clients broken down by gender and age and reason for prophylaxis who received PEP during the reporting period. Numerator: Total number of clients who are active on Post Exposure prophylaxis at this facility, distributed by gender, age and reason for prophylaxis at the end the reporting period. Interpretation The indicator monitors the number clients who were active on PEP at the end of the reporting period. It can also be used to measure drug stock requirements for PEP. Response The indicator can be used to monitor drug stock requirements for PEP and reasons for commencing PEP so as to institute necessary interventions. Analysis Guidelines This should be analyzed quarterly and annually at facility, district, provincial and national level. Data Source: Monthly Summary Sheet, Column ID (g). ART/HMIS Materials – Indicators Manual 7
- 10. 8 TOTAL NUMBER OF PATIENTS CURRENTLY ON PROPHYLAXIS. Goal: To monitor the number of clients receiving prophylaxis at the facility at the end of the reporting period. Definition of Indicator This is the number of clients broken down by gender and age and type of prophylactic treatment being received at the end of the reporting period. Numerator: Total number of clients who were on prophylaxis at this facility, distributed by gender, age and type of prophylactic treatment at the end the reporting period. Interpretation The indicator monitors the number clients who were active on prophylaxis at the end of the reporting period. It can also be used to estimate drug stock requirements for prophylaxis. Response The indicator can be used to monitor drug stock requirements for prophylaxis. Analysis Guidelines This should be analyzed quarterly and annually at facility, district, provincial and national level. Data Source: Monthly Summary Sheet, column ID (h). 9 PERCENTAGE OF COHORT PATIENTS ALIVE AND ON ART AFTER 6, 12 AND 24 MONTHS Goal: To monitor if and how long ART reduces mortality or prolong the lives of people living with HIV /AIDS. Definition of Indicator This is a cohort analysis of patients who started ART 6, 12 and 24 months ago. It has sub- indicators for each cohort maturity. ART/HMIS Materials – Indicators Manual 8
- 11. 9.1 Percentage of patients alive and on ART after 6 months Numerator: The number of patients on ART (6mths) Denominators: The number of patients who started ART 6 months ago 9.2 Percentage of patients alive and on ART after 12 months Numerator: The number of patients on ART (12mths) Denominators: The number of patients who started at 12 months ago 9.3 Percentage of patients alive and on ART after 24 months Numerator: The number of patients on ART (24mths) Denominators: The number of patients who started at 24 months ago Interpretation The survival rates of patients must be monitored according to duration on ART. It is expected that the longer a group of patients stay on ART the higher the chances of survival. It would also be interesting to know on the long term how long people survive with ART. Further, differentiation of % of patients alive after 5 years, 10 years or more might be needed. Response All situations must be investigated. Analysis Guidelines This indicator should be analyzed quarterly and annually at facility, district, province and national levels. Data Sources: Monthly and Cohort Summary Sheet 10 PROPORTION OF PATIENTS STILL ON 1ST LINE ART 12 MONTHS AFTER INITIATING ART. Goal: To monitor which proportion of patients is still on 1st line drugs of ARV a year after initiating ART Definition of Indicator Numerator: Number of people still on first line drugs 12 months after starting Denominator: Number of people alive and on ART ART/HMIS Materials – Indicators Manual 9
- 12. Interpretation First line ARV drugs should be maintained as long as possible in order to reduce resistance levels. Response High number of patients switching to second level should be investigated. Analysis Guidelines This indicator should be analyzed quarterly and annually at facility, district, province and National level. Data Sources: Monthly and Cohort Summary Sheet 11 PROPORTION OF PATIENTS STILL ON ORIGINAL 1ST LINE REGIMEN 12 MONTHS AFTER INITIATING ART. Goal: To monitor proportion of patients that is still on same original ART during 1st year Definition of Indicator Numerator: Number of patients still on original regimen Denominator: Number of patients on ART Interpretation First line ARV drugs should be maintained as long as possible in order to minimise drug resistance. The more patients we have on original first line 12 months after initiation the better. Response A high incidence of patients switching to another 1st line drug regimen or to a second level should be investigated to establish if it is a problem of subscribers, drug availability or side effects of the drugs themselves. Analysis Guidelines This indicator should be analyzed quarterly and annually at facility, district, province and National level. Data Sources: Monthly and Cohort Summary Sheet ART/HMIS Materials – Indicators Manual 10
- 13. 12 PROPORTION OF PATIENTS WHO HAVE SUBSTITUTED TO AN ALTERNATIVE 1ST LINE REGIMEN AFTER 12 MONTHS OF INITIATING THERAPY. Goal: To keep patients on the 1st line ARV drugs as long as possible. Definition of Indicator Numerator: Patients who SUBSTITUTED to alternative 1st line ARV during quarter Denominator: Number of patients on ART Interpretation First line ARV drugs should be maintained as long as possible in order to reduce resistance levels. The more patients we have on original first line 12 months after initiation the better. Response A high incidence of patients switching to alternative 1st line ARV should be investigated to establish if it is a problem of subscribers, drug availability or complications with patients. Analysis Guidelines This indicator should be analyzed quarterly and annually at facility, district, province and National level. Data Sources: Monthly and Cohort Summary Sheet 13 PROPORTION OF PATIENTS WHO HAVE SWITCHED TO A 2ND LINE (OR HIGHER) REGIMEN AFTER 12 MONTHS OF INITIATING THERAPY. Goal: To monitor proportion switching to 2nd line during 1st year with the aim of keeping patients on the 1st line drugs. Definition of Indicator Numerator: Patients who switched to 2nd line ARV during quarter Denominator: Number of patients on ART Interpretation First line ARV drugs should be maintained as long as possible in order to reduce resistance levels. The more patients we have on original first line 12 months after initiation the better. ART/HMIS Materials – Indicators Manual 11
- 14. Response A high incidence of patients switching to 2nd line ARV should be investigated to establish if it is a problem of subscribers, drug availability or complications with patients. Analysis Guidelines This indicator should be analyzed quarterly and annually at facility, district, province and national level. Data Sources: Monthly and Cohort Summary Sheet ART/HMIS Materials – Indicators Manual 12