Implementation of routine HIV viral load monitoring A

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Implementation of routine HIV viral load monitoring A multisite cascade analysis Munyaradzi Dhodho 1,

Implementation of routine 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 5 1 Médecins Sans Frontières (MSF), Harare, Zimbabwe; 2 MSF, Cape Town, South Africa; 3 MSF, Blantyre, Malawi; 4 MSF, Maputo, Mozambique; 5 MSF Southern Africa Medical Unit, Cape Town, South Africa

Reaching The Third 90 90% Know their HIV status 90% Are retained on ART

Reaching The Third 90 90% Know their HIV status 90% Are retained on ART 90% Have a suppressed viral load

Reaching The Third 90 Globally Less than 30% of patients have access to viral

Reaching The Third 90 Globally Less than 30% of patients have access to viral load (VL) testing National VL Coverage Malawi 17% Zimbabwe 5% 90% Know their HIV status 90% Are retained on ART 90% Have a suppressed viral load

Background • From 2012, routine VL testing was introduced in 6 MSF projects in

Background • From 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 ) Malawi Thyolo and Nsanje Mozambique Changara Zimbabwe Buhera and Gutu Lesotho Roma

Background • All sites scaled up VL testing using – Dried Blood Spot samples

Background • All sites scaled up VL testing using – Dried Blood Spot samples ( DBS) – Using a centralised high throughput VL platform (bio. Mérieux Nucli. SENS) • All sites performed annual viral load except Malawi (every 2 years )

Objective: To Assess The Viral Load Cascade in each site Step 1: Coverage of

Objective: To Assess The Viral Load Cascade in each site Step 1: Coverage of Viral Load Testing

Objective: To Assess The Viral Load Cascade at each site Step 1: Coverage of

Objective: To Assess The Viral Load Cascade at each site Step 1: Coverage of Viral Load Testing Step 2: Acting on the result (< or > 1000 copies/ml) Differentiate ART delivery ( Clubs, CAGs, fast track) Counselling and Repeat VL

Objective: To Assess The Viral Load Cascade at each site Step 1: Coverage of

Objective: To Assess The Viral Load Cascade at each site Step 1: Coverage of Viral Load Testing Step 2: Acting on the result (< or > 1000 copies/ml) Differentiate ART delivery ( Clubs, CAGs, fast track) Counselling and Repeat VL Remain on 1 st Line Switch to Second Line

Methods • Analyses performed between Jan and Nov 2015 • Reviews of clinical and

Methods • Analyses 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

Results: Coverage ( n=24, 263) Site Year routine VL testing started Number of patients

Results: Coverage ( n=24, 263) Site Year routine VL testing started Number of patients in the analysis Coverage of routine VL testing (VL 1) Buhera, Zimbabwe Gutu, Zimbabwe Thyolo, Malawi Nsanje, Malawi Roma, Lesotho Changara, Mozambique 2012 2013 2014 2013 4760 2978 7576 2785 3069 3095 24263 91% 74% 56% 32% 70% 62% 65% Total Routine VL Coverage 32 -91%

Results Site Year routine VL testing started Number of patients in the analysis Coverage

Results Site Year routine VL testing started Number of patients in the analysis Coverage of routine VL testing (VL 1) VL > 1000 copies/ml Buhera, Zimbabwe Gutu, Zimbabwe Thyolo, Malawi Nsanje, Malawi Roma, Lesotho Changara, Mozambique 2012 2013 2014 2013 4760 2978 7576 2785 3069 3095 91% 74% 56% 32% 70% 62% 14% 15% 9% 20% 10% 40% % > 1000 copies/ml 9 -40%

Results: Coverage Success Challenge Task-shifting of sample preparation to lay workers Poor patient triage

Results: Coverage Success Challenge Task-shifting of sample preparation to lay workers Poor patient triage and patient flow Use of electronic medical records (EMRs) to flag patients due for VL Demand creation with patients Prolonged turnaround time from laboratory demotivation

Results: Action on High Viral Load 80 70 70 68 60 46 50 40

Results: Action on High Viral Load 80 70 70 68 60 46 50 40 37 30 Lowest 23 22 20 10 0 Documented EAC VL repeated Suppressed to < 1000 copies/ml Highest

Results: Switch To Second Line Initiations on second line ART Buhera, Zimbabwe Gutu, Zimbabwe

Results: Switch To Second Line Initiations on second line ART Buhera, Zimbabwe Gutu, Zimbabwe 282 257 • Overall switch rates were low • Between 10 and 38% 100 62 11 2008 30 0 2009 2010 24 48 44 5 12 2011 2012 2013 2014 2015

Results: Action on High Viral Load Success Barrier Dedicated VL focal person to Poor

Results: Action on High Viral Load Success Barrier Dedicated VL focal person to Poor patient triage identify and follow-up patients No dedicated staff member to perform enhanced Flagging of results adherence counselling (EAC) Use of EAC register and High Viral Load (HVL) form Lack of supervision and follow up Monthly lists identifying patients with a HVL for supervision team to use Lack of task-shifting and decentralisation of secondline ART initiation

Cost of No Action • Financial cost of taking a VL test and not

Cost of No Action • Financial 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 taken • Patient cost – timely switch to second line • Public health cost – ongoing HIV transmission

Conclusion • Scaling up VL is feasible in resource poor settings • Analysing the

Conclusion • Scaling 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 capacity • There is an urgent need to task shift and decentralise second-line ART initiation and follow-up

Acknowledgements Ministries of Health, MSF field teams and the patients in Lesotho, Malawi, Mozambique

Acknowledgements Ministries of Health, MSF field teams and the patients in Lesotho, Malawi, Mozambique and Zimbabwe