(TX_RET) Percentage of adults and children known to be on treatment 12 months after initiation of antiretroviral therapy (Note: reporting 24 and 36 months is recommended, but optional)

Export Indicator

Percentage of adults and children known to be on treatment 12 months after initiation of antiretroviral therapy (Note: reporting 24 and 36 months is recommended, but optional)
What it measures

This indicator measures the proportion of individuals who have been 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. 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.

Numerator

Number of adults and children who are still on treatment at 12 months after initiating ART

Denominator

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 and those who have stopped ART. Does not include transfer outs.

Calculation

Use result reported at Q4/APR; Numerator should be divided by denominator to determine % retained; % retained for pregnant and breastfeed women; as well as children <15 % retained should be calculated separately and used to assess these programs.

Method of measurement

Information should come from electronic systems (EMR) if possible. Where electronic systems do not exist ART registers/databases and cohort/group analysis forms can be used to count patients that have been retained after 12, 24 or 36 months on ART.

This indicator should NOT be estimated. This indicator should be calculated directly from information gathered in standard cohort ART registers or electronic patient level databases.

Sites are required to disaggregate retention by pregnancy and breastfeeding and specific age/sex disaggregates (see data element below). In order to collect this information ART registers, cohort/group analysis forms, and EMRs must document age, sex, pregnancy status, and breastfeeding status on the date of ART initiation.

Of note, for reporting purposes a three-month grace period should be observed following drug pick-up, before concluding a patient is actually LTFU. However, while practical, if follow-up of patients is delayed till LTFU is official the majority of clients who do not present by three months of last missed appointment/drug pick-up are very unlikely to return thereafter. Therefore, for patient management, the facility should make every effort to contact a patient as soon as s/he misses an appointment and/ or drug pick-up (by phone, via community health worker) rather than waiting for the prescribed 90 days. This is particularly important when patients are routinely seen every three to six months (a patient may not have been seen for up to nine months if the facility adheres to the waiting period before attempting contact). LTFU is an ambiguous outcome that may often include patients who have self-transferred (silent transfer, without proper documentation or referral from their original primary care facility) or have died for which there is no documentation. Every effort should be made to document the more concreate outcomes for those not on ART (i.e. died, stopped ART, transfer out) to make the information more useful.

How to review for data quality:

-  TX_RET Denominator ≥ TX_RET Numerator

- Denominator ≥ subtotal of each disaggregation

o The total number of adults and children who initiated ART in the past 12 months should be greater or equal to the sum of the disaggregations by (1) Pregnancy/breastfeeding status and (2) age/sex

- Numerator ≥ subtotal of each disaggregation

o The total number of adults and children still on treatment at 12 months should be greater or equal to the sum of the disaggregations by (1) Pregnancy/ breastfeeding status and (2) age/sex

- Number of PEPFAR supported sites that report TX_RET vs number of sites that report TX_CURR by region to determine completeness of reporting

Reporting level

Site level, facility only

Measurement frequency

Report 12 months of results at Q4

Disaggregation

Numerator (Required): Number of adults and children in the cohort, who are still on treatment at 12 months after initiating ART.

Longer term retention (Optional)

24, 36 month

Pregnant/Brea st Feeding (Required)

Pregnant; Breastfeeding

Age/Sex (Fine Disaggregate)

<1, 1-9, 10-14 M, 10-14 F, 15-19 M, 15- 19 F, 20-24 M, 20-24 F, 25- 49,M 25-49F, 50+ M, 50+ F

Age/Sex (Course Disaggregate) (Conditional)

<15 M, <15 F, 15+ M, 15+ F

Description of Disaggregate

Although optional, it is recommended for sites to include their longer term ART retention numbers (including 24 and 36 months);

Pregnancy and Breastfeeding status is defined as the status at the date of initiation on ART, not the status at the date of reporting.

Age is defined as the age at the date of initiation on ART, not the age at the date of reporting.

This disaggregation should only be entered if finer age disaggregates are not available.

Denominator:

Total number of adults and children who initiated ART in the 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 during the subsequent 12 months.

Longer term retention (Optional)

24, 36 month

Pregnant/Brea st Feeding (Required)

Pregnant; Breastfeeding

Age/Sex (Fine Disaggregate) (Required)

<1, 1-9, 10-14 M, 10-14 F, 15-19 M, 15- 19 F, 20-24 M, 20-24 F, 25- 49,M 25-49F, 50+ M, 50+ F

Age/Sex (Course Disaggregate) (Conditional) 

<15 M, <15 F, 15+ M, 15+ F

Description of Disaggregate

Although optional, it is recommended for sites to include their longer term ART retention numbers (including 24 and 36 months);

Pregnancy and Breastfeeding status is defined as the status at the date of initiation on ART, not the status at the date of reporting

Age is defined as the age at the date of initiation on ART, not the age at the date of reporting.

This disaggregation should only be entered if finer age disaggregates are not available.

Explanation of the numerator

The numerator is defined as the number of adults and children who are still on treatment twelve months after initiating ART.

For example, if the PEPFAR reporting period is 1 October 2016 to 30 September 2017, countries will calculate this numerator by using all patients who started ART any time during the 12-month period from 1 October 2015 to 30 September 2016. The 12-month outcomes are defined as 1) on ART and 2) not on ART because patient died, stopped ART or was lost to follow-up (LTFU), (including silent transfers).

On ART is defined as those patients who had received enough ARVs to last to the end of the reporting period. See example below for more details.

LTFU is defined as a patient who has not received ARVs in the last 90 days (three months) following their last missed appointment or missed drug pick-up.

Died: Patients that are documented death during the previous 12 months period.

Stopped ART: Patient intentionally stops ART, usually, but not always in discussion with the clinical team.

Known Transfers: 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 the numerator (or denominator, see below)

Note: this indicator does not collect adherence information, but only retention, therefore 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 2016 would be considered “on ART at 12 months” (in September 2017) if:

- The patient visited the facility and received ARVs in September 2017; OR

- The patient had enough ARVs to last through the end of September 2017 (month 12) based on the last drug pick-up (e.g., patient received 60 days of drug on August 15th, or patient received 90 days of drug on July 1st, etc.).

However, the patient would NOT be considered “on ART at 12 months” if:

- The patient did NOT have enough ARVs to last through the end of September 2017 (e.g., patient received 30 days of drug on August 1st); OR

- The patient had died, transferred out, stopped ART, or was lost to follow-up at the end of September 2017.

Explanation of the denominator

The denominator is defined as the number of all adults and children who were initiated on treatment in the 12-month period before the reporting period. The denominator 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. However, transfers-out should be taken out of both 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.

For example, for the reporting period October 1, 2016 to September 30, 2017, this will include all patients who started ART during the 12- month period from October 1, 2015 to September 30, 2016. This includes all patients, both those on ART as well as those who have died, stopped ART or were lost to follow-up (LTFU).

Only sites that have been operational for at least 24 months prior to the end of the reporting period should report. PEPFAR country teams may use the USG FY reporting period as the timeframe for the 12- month cohort. Teams may also wish to ‘lag’ by 1-3 months the cohortmonths comprising the annual cohort, in order to allow sufficient time for reporting from data sources (i.e., implementing partners and/or national systems).

Further information

MER 1.0 to 2.0 Change

Age/Sex disaggregates aligned across clinical cascade.

24 and 36 months were added as optional time periods to monitor changes to retention of these patients as models of service delivery change for stable patients on ART (the definition of stable varies across contexts, but often excludes patients on ART for less than 12 months)

(Note: As models of service delivery change to reflect longer visit intervals for stable patients, it is important to emphasize the definition of LTFU applies to both missed visits or missed drug pick-up, but does not apply who have not received ARVs in the last 90 days (three months) following their last attended appointment or attended drug pick-up. As that interval between scheduled visits for stable patients maybe longer than 3 months.)

PEPFAR Support definition

Standard definition of DSD and TA-SDI used

Provision of key staff or commodities for PLHIV receiving ART include: the provision of key staff and/or commodities 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.

Ongoing support for PLHIV receiving ART service delivery improvement includes: 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

DREAMS SNU Specific Guidance

None