Making Viral Load Routine Implementation experience from MSF Dr Helen Bygrave IAC 2016 Programmatic and Laboratory Must Speak to Each Other wwwmsfaccessorgmakingviralloadroutine Sites for Routine VL monitoring ID: 770525
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Making Viral Load Routine Implementation experience from MSFDr Helen Bygrave IAC 2016
Programmatic and Laboratory Must Speak to Each Other www.msfaccess.org/makingviralloadroutine
Sites for Routine VL monitoring 10 ART Programmatic Sites189,795 Patients on ART Lesotho ( Roma ) Malawi ( Thyolo, Nsanje, Chiradzulu)Mozambique ( Changara , Maputo) Swaziland ( Shiselweni)Uganda ( Arua ) Zimbabwe ( Gutu , Buhera) 7 + 1 VL Laboratories: 320,000 tests performed Biomerieux Harare NMRL Maputo ( moving to Abbott) Thyolo , Malawi( moved to Abbott) Biocentric Shiselweni , Swaziland Abbott Kinshasa DRC SAMBA 1 Chiradzulu , Malawi Arua , Uganda Xpert HIV-1VL Gutu Zimbabwe
MSF experience: Programmatic Strategies:Knowing Your viral load cascade How are we going to get this data ?
VL Cascade VL Coverage % > 1000 copies/ml % receiving Enhanced Adherence Counselling % Getting a repeat VL % with second high VL above threshold switched to second lin e
32-91% Coverage of Routine Viral Load Health System The Role of lay workers in taking the samples Education of health care workers to recognise value of viral load Setting clear monthly clinic targets for VL Health system strengthening – triage and patient flow – flagging to identify clients in need of VL ( Use of EMRs)
Demand Creation from Civil Society :Knowing when VL should be takenWhat VL means What action needed depending on the result Investing in client education material- Needs funding Will group ART refill strategies such as CAGs and Clubs help? 32-91% Coverage of Routine Viral Load Adherence Clubs: VL uptake 67% v 49% CAGs Mozambique: VL uptake 72%v 47%
Value of a “ Good Result”Qualitative work Swaziland ( Horter et al)Offer Differentiated Care “It encourages me to hold on and take my treatment as prescribed ” ( Client Shishelweni Swaziland)
56-82% documented Enhanced Adherence 23-71% repeat VL taken
Health systems strengthening for flagging clients in need of EAC and repeat VLTools EAC register and High VL form – need funding ?Supervision and mentorship Who’s doing the EAC ?24-50% suppressed after EAC to < 1000 copies/ml
Access to second line drugs where the patient isDecentralisationTask shifting Remote Switch decision supportApps Sending case summary to district levelPerceptions of second line from HCW and Clients 10-68% of those eligible switched to second line ART
Part 2: The laboratory
Is plasma feasible on centralised platforms? Swaziland ExperienceSeeing ART patients daily but unable to have sample transport dailyTrained lay workers to perform phelbotomy and centrifuge samples that are refrigerated at primary care level Reduced sample transport to twice weekly Yes but investment in HR and coordinated sample transport
Strategies that have supported VL scale up DBS centralised platform Biomerieux and Abbot Plasma -Near POC SAMBA 1 Xpert HIV -1 VL
Lessons Learned Setting Up Centralised VL Testing Platforms To purchase or lease Controls costs Flexibility Inclusion of maintenance in costPossible incentive for better maintenanceInfrastructureAdequate space Power / water supplyStorage space for consumablesRetention of specialised laboratory technicians Development of laboratory information systems for VL: programmed to produce clinically useful lists and triggers WASTE MANAGEMENT No guidance No regulation 10mg cyanide from every kg of VL waste
Lessons Learned Keeping a VL Laboratory Running Power supply : plan for longer UPS MaintenanceTraining of local staff to perform maintenance Availability of parts in country or regionally All machines underutilised- link between ART programme / VL cascade data and VL scale up planning HR management : Setting clear targets for throughput
Back Up Planning Must be Part of the PlanIn or out of country : Public or private
Experience with Near Point of Care Allows task shifting for sample processing ( Study Chiradzulu – excellent concordance of results lay worker v lab technician) SAMBA 1 ( Malawi / Uganda ) 80% of clients received results on the same day Xpert – polyvalency – Study in Zimbabwe concurrent testing of VL , EID , TB , HPV on same platform in same clinicSimpler to set upDown time much less – modular repairsLower Error rates
Some Questions Going Forward How do we best use centralised, near POC and true POCCoordination of donors across programmatic and laboratory needs Funding of layworkers crucial to coverage of VL and provision of enhanced adherence Access to timely second line switch ; and perceptions of second line therapy
Thanks to All the MSF Field Teams Collaborating Ministries of Health People Living with HIV in the MSF supported projects UNITAID