Percentage of health facilities providing ART using CD4 monitoring in line with national guidelines or policies, either on site or through referral [disaggregated by sector (public, private)]

Export Indicator

Percentage of health facilities providing ART using CD4 monitoring in line with national guidelines or policies, either on site or through referral, disaggregated by sector (public, private). Health facilities include public and private facilities, health
What it measures

This indicator measures the percentage of health facilities providing ART using CD4 monitoring. Although the unavailability of CD4 monitoring should not be a barrier to providing ART, WHO recommends CD4 monitoring for better and more accurate clinical decision-making. This indicator may also be used as a proxy measure of the quality of ART services provided in a country.

Rationale

Current WHO guidelines recommend that patients with advanced or severe symptomatic HIV disease should start ART irrespective of CD4 cell count. Although the optimum time to start ART has not been firmly established, it is known to be before patients become unwell or present with HIV-associated opportunistic diseases. Immunologic monitoring (i.e., CD4 testing), where possible, is the best approach to guide the decision on when to initiate ART in asymptomatic individuals and to monitor ART responses in patients receiving ART.
In many resource-limited settings where ART services are being scaled up, decisions to initiate ART are based upon clinical assessment. As ART services expand, health system infrastructure should be strengthened where possible to make CD4 testing more readily available. Making CD4 testing available allows asymptomatic but immunologically compromised individuals to start ART earlier and improves the quality of care of HIV patients through better treatment monitoring. Furthermore, CD4 testing is also useful to expand access to cotrimoxazole prophylaxis in HIV-infected patients as part of the pre-ART care package.
 

Numerator

Number of health facilities providing ART using CD4 monitoring in line with national guidelines or policies, either on site or through referral.

Denominator

Total number of all health facilities providing ART.

Calculation

Number of health facilities providing ART using CD4 monitoring in line with
national guidelines or policies, either on site or through referral
------------------------------------------------------------------------------------------------------------------------- x 100
Total number of health facilities providing ART

Method of measurement

National ART Programmes should have a record of all facilities that provide CD4 testing services, whether on site or through referral. This is a national list or inventory of sites with CD4 testing available, or of reference laboratory networks with a list of facilities that link with these laboratories to provide CD4 testing.
 
A health facility census or survey can also provide this information as well as more in-depth information on services available, provided the information is collected from a representative sample of health facilities in the country. In a facility survey (e.g., Service Provision Assessment, Service Availability Mapping), the most knowledgeable person responsible for client services is interviewed using the AIDS Outpatient Department (OPD) module. Responses to a series a questions establish whether the facility uses CD4 monitoring on site or through referral. In addition, facility records documenting the current status of service provision should be consulted. One potential limitation to facility surveys or censuses is that they are usually only conducted once every few years. Countries should regularly update their programme records on health facilities offering ART services, and supplement these data with those obtained through a health facility survey or census every few years.
 

Measurement frequency

Annual

Disaggregation

Sector: Private, Public

Explanation of the numerator
Explanation of the denominator
Strengths and weaknesses

This indicator measures the availability of CD4 monitoring in health facilities providing ART, and can provide a quick indication of improvement in earlier access to ART and the quality of ART services nationwide. It does not provide detailed information on the quality of ART services or improved treatment outcomes.

Further information