Multi-disease diagnostic integration - PowerPoint Presentation

1. Multi-disease diagnostic integrationOptimizing utilization of existing devices in Zimbabwe to expand access to testing for HIV Viral Load

2. AgendaBackground – Zimbabwe Country SituationIntegrated testing pilot – proof of conceptComprehensive VL Scale up plan

3. BackgroundThere are about 1.3M people living with HIV (PLHIV) in ZimbabweHIV services are decentralized, however access to nucleic acid testing (NAT) for early infant diagnosis (EID), and viral load (VL) monitoring, are centralized.In 2017, the estimated VL coverage was 30%At the time, VL testing platform capacity was inadequate to meet programmatic VL demand There was a lack of systems to quickly deliver VL results back to health facilities within one weekIn 2016, Zimbabwe had 130 GeneXpert (Xpert) procured under the TB program, with an estimated overall device utilization of 27%, used only for TB testingXpert EID and VL were approved for clinical use by the end of 2016MOHCC determined there was a need to increase coverage and quality of VL in the context of excess capacity on existing Xpert devices

4. AgendaBackground – Zimbabwe Country SituationIntegrated testing pilot – proof of conceptComprehensive VL Scale up plan

5. MOHCC conducted an integration pilot to determine feasibilityDuration5 months (Oct ‘17 – Feb ‘18)Number of Health Facilities8 urban health facilities: 4 EID/VL/TB & 4 VL/TB only (already had POC EID)Selection of facilities where projected TB demand, EID demand and VL demand could be accommodatedBaseline EID/VLDBS to Central labPilot EID/VLXpert placed in lab, operated by lab staffVL prioritizationPregnant and breastfeeding womenChildren and AdolescentSuspected failures TB and HIV programs agreed to pilot integrated EID, targeted VL and TB testing on existing GeneXpert devices

6. Adding HIV testing to existing GeneXpert devices demonstrated increased device utilization without exceeding machine capacity75%Target optimal utilization* Zimbabwe annual throughput GXIV: 2880 Device Utilization Across EID/TB/VLEID and targeted VL testing volumes can be accommodated on existing GeneXpert devices that are in operation in laboratories= VL= EID= TBKey

7. Onsite VL was effectively targeted, improved quality of care for viremic clients, without compromising TB testing and clinical careOn-site VL enabled faster EID and VL testingA greater proportion of patients with elevated VL received their results: 48% at baseline and 96% during the pilotA greater proportion of patients with elevated VL had a documented a clinical action (either EAC or 2L switch): 48% improved to 83% Timeliness of TB testing and treatment initiation for Mtb+ patients did not change with the additional HIV testing:Median 2 days (IQR:1-3) from sample collection to patient receipt of result both pre/post47% treatment initiation in baseline and 48% during pilotOverall device utilization increased which may enable cost-efficienciesWith appropriate planning, integrated HIV-TB testing was feasible, demonstrating synergies across the two programs

8. AgendaBackground – Zimbabwe Country SituationIntegrated testing pilot – proof of conceptComprehensive VL Scale up plan

9. Zimbabwe has recently launched The Viral Load Scale Up PlanRoad Map to guide VL testing scale-up in Zimbabwe from 30% (end of 2017) to >95% by the end of 2020 as follows:2018 60% of those PLHIV on ART2019 80% of those PLHIV on ART 2020 95% of those PLHIV on ART Establish collaboration and coordination between government and partners as they provide VL testing services in the countryUtilize Diagnostics Network Optimization for efficient integration of testing Provide clear direction on procurement and supply chain strategies for VL testing services to allow for improved and sustainable access9GOAL: Expand clinical and laboratory capacity to conduct at least 1 million VL tests annually for routine VL monitoring for all PLHIV on ART by the end of 2019. Source: Zimbabwe Viral Load Scale up plan 2018-2020

10. There are 22 conventional instruments currently available and operational across the country with a capacity of 934,000 test per year currently10Source: Zimbabwe Viral Load Scale up plan 2018-2020

11. GeneXpert platforms in the country provide an opportunity to expand access to VL Testing particularly for relevant key population VL Testing capacity plan POC VL could be particularly relevant in specific populations to reduce onward HIV transmission11Population Reason Pregnant WomenTo ensure viral suppression to minimize MTCT and/or identify infants at high risk of infection who should be prioritized for enhanced ARV prophylaxis at birth.Lactating MothersTo ensure viral suppression to minimize MTCTIndividuals in sero-discordant couplesEnsuring viral suppression is important to reduce onward HIV transmission riskChildren, adolescents, failure suspects, patients with advanced diseaseAt higher risk of having elevated VL and would benefit from prompt EAC services or regimen switchSource: Zimbabwe Viral Load Scale up plan 2018-2020

12. Opportunities in Zimbabwe: VL testing landscapeThrough diagnostics network analysis utilizing existing 22 centralized NAT systems to design rational sample referral systemsCurrently of the 130 existing near POC GeneXpert devices, 41 are multiplexing TB, HIV and EIDConsensus built between TB/HIV programs through the initial pilotThe country has 57 mPima platforms: plans are already underway to evaluate the mPima for VL for multiplexing (already in use for EID)Through a blend of centralized, near POC and POC, Zimbabwe expects to reach its VL testing targets, leveraging integration12

13. Questions?13