HIV viral load monitoring A multisite cascade analysis Munyaradzi Dhodho 1 Marthe Frieden 1 Amir Shroufi 2 Esther Wanjiru 3 Sarah Daho 3 Erica Simons 4 Helen Bygrave ID: 806623
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Implementation of routine HIV viral load monitoringA multisite cascade analysis
Munyaradzi Dhodho1, Marthe Frieden1, Amir Shroufi2, Esther Wanjiru3, Sarah Daho3, Erica Simons4, *Helen Bygrave51Médecins Sans Frontières (MSF), Harare, Zimbabwe; 2MSF, Cape Town, South Africa; 3MSF, Blantyre, Malawi; 4MSF, Maputo, Mozambique; 5MSF Southern Africa Medical Unit, Cape Town, South Africa
Slide2Reaching The Third 90
90% Know their HIV status 90% Are retained on ART 90% Have a suppressed viral load
Slide3Reaching The Third 90
90% Know their HIV status 90% Are retained on ART 90% Have a suppressed viral load Globally Less than 30% of patients have access to viral load (VL) testing National VL Coverage Malawi 17%Zimbabwe 5%
Slide4BackgroundFrom 2012, routine VL testing was introduced in 6 MSF projects in Lesotho, Malawi (2), Mozambique, and Zimbabwe (2).
All districts were rural settings where ART had been extensively decentralised to primary care clinics (10-30 clinics/district ) MalawiThyolo and Nsanje MozambiqueChangaraZimbabwe Buhera and Gutu LesothoRoma
Slide5Background All sites scaled up VL testing using Dried Blood Spot samples ( DBS) Using a centralised high throughput VL platform (bioMérieux NucliSENS)All sites performed annual viral load except Malawi
(every 2 years )
Slide6Objective:To Assess The Viral Load Cascade in each site
Step 1: Coverage of Viral Load Testing
Slide7Objective:To Assess The Viral Load Cascade at each site
Step 2: Acting on the result(< or > 1000 copies/ml)Differentiate ART delivery ( Clubs, CAGs, fast track) Counselling and Repeat VL
Step 1: Coverage of Viral Load Testing
Slide8Objective:To Assess The Viral Load Cascade at each site
Step 2: Acting on the result(< or > 1000 copies/ml)Differentiate ART delivery ( Clubs, CAGs, fast track) Counselling and Repeat VL
Step 1: Coverage of Viral Load Testing
Remain on 1
st
Line
Switch to Second Line
Slide9MethodsAnalyses performed between Jan and Nov 2015 Reviews of clinical and laboratory records to determine how each step of the VL cascade was
implemented within a defined period according to local guidelines Results were presented to programme staff and barriers for implementation identified
Slide10Results: Coverage ( n=24,263)
SiteBuhera, ZimbabweGutu, ZimbabweThyolo, MalawiNsanje, MalawiRoma, LesothoChangara, MozambiqueTotalYear routine VL testing started
2012
2013
2012
2013
2014
2013
Number of patients in the analysis
4760
2978
7576
2785
3069
3095
24263
Coverage of routine VL testing (VL1)
91%
74%
56%
32%
70%
62%
65%
Routine VL Coverage 32-91%
Slide11Results
SiteBuhera, ZimbabweGutu, ZimbabweThyolo, MalawiNsanje, MalawiRoma,Lesotho Changara,MozambiqueYear routine VL testing started
2012
2013
2012
2013
2014
2013
Number of patients in the analysis
4760
2978
7576
2785
3069
3095
Coverage of routine VL testing (VL1)
91%
74%
56%
32%
70%
62%
VL > 1000 copies/ml
14%
15%
9%
20%
10%
40%
% > 1000 copies/ml 9-40%
Slide12Results: CoverageSuccess
ChallengeTask-shifting of sample preparation to lay workersUse of electronic medical records (EMRs) to flag patients due for VL Demand creation with patients Poor patient triage and patient flowProlonged turn-around time from laboratory demotivation
Slide13Results: Action on High Viral Load
Slide14Results: Switch To Second LineOverall switch rates were lowBetween 10 and 38%
Slide15Success
Barrier Dedicated VL focal person to identify and follow-up patientsFlagging of results Use of EAC register and High Viral Load (HVL) form Monthly lists identifying patients with a HVL for supervision team to use Poor patient triageNo dedicated staff member to perform enhanced adherence counselling (EAC)Lack of supervision and follow up Lack of task-shifting and decentralisation of second- line ART initiationResults: Action on High Viral Load
Slide16Cost of No ActionFinancial cost of taking a VL test and not acting e.g in Changara $8865 spent on VL tests with result > 1000 copies/ml but no action takenPatient cost – timely switch to second linePublic health cost – ongoing HIV transmission
Slide17ConclusionScaling up VL is feasible in resource poor settings Analysing the VL cascade at site level is essential to ensure tests are taken and results utilised Equal investment must be made into programmatic implementation of VL, as in establishing VL testing capacityThere is an urgent need to task shift and decentralise second-line ART initiation and follow-up
Slide18Acknowledgements
Ministries of Health, MSF field teams and the patients in Lesotho, Malawi, Mozambique and Zimbabwe