Viral Load Monitoring Monitoria da Carga Viral Dr

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Viral Load Monitoring Monitoria da Carga Viral Dr Malebo Maponyane MBCHB; DPH; BSc September

Viral Load Monitoring Monitoria da Carga Viral Dr Malebo Maponyane MBCHB; DPH; BSc September 2017 - Chimoio

Objectives • Understanding Viral Load • Compreender a Carga Viral • Viral Load and

Objectives • Understanding Viral Load • Compreender a Carga Viral • Viral Load and HIV Infection • Carga Viral e Infecção de HIV – Disease Progression – Progressão da Doença – Disease Transmission – Transmissão da Doença • Viral Load Measurement and Reporting • Menção e Relato da Carga Viral • Viral Load Response to ART • Resposta da Carga Viral em TARV • Treatment Failure • Falência Terapéutica – Criteria – Critérios – Routine and Targeted Viral Load – Rotina e Monitoria da Meta da Monitoring • Schedule of Viral Load Monitoring Carga Viral • Programa de Monitoria da Carga Viral

What is Viral Load? O que é Carga Viral? • The HIV-1 viral load

What is Viral Load? O que é Carga Viral? • The HIV-1 viral load measurement indicates the number of copies of HIV-1 RNA per milliliter of plasma. A medida da Carga Viral do HIV-1 indica o número de cópias de HIV-1 RNA por mililitro de plasma • Although HIV ultimately resides within cells, the plasma measurement is an accurate reflection of the burden of infection and the magnitude of viral replication. Embora o HIV ultimamente resida dentro das células, a medida da plasma é uma reflexão precisa de barreiras de infecção e a magnitude de reprodução viral.

What is Viral Load? O que é Carga Viral? • It is used to

What is Viral Load? O que é Carga Viral? • It is used to assess the risk of disease progression and can help guide initiation of therapy. É usado para avaliar o risco de progressão da doença e pode ajudar a iniciação da terapia. • It is critical in monitoring virologic response to ART. É crítico na resposta de monitoria virológica ao TARV

Classification of HIV: • HIV (Human Immunodeficiency Virus) • belongs to the genus Lentivirus

Classification of HIV: • HIV (Human Immunodeficiency Virus) • belongs to the genus Lentivirus (slow poison) • family Retroviridae (backwards virus). Transcription (RNA Polymerase) DNA Translation (Ribosome) RNA Reverse Transcription (Reverse Transcriptase) PROTEIN

HIV life cycle

HIV life cycle

Immune response to HIV Chronic, asymptomatic Phase of infection Acute Infection AIDS CD 4+

Immune response to HIV Chronic, asymptomatic Phase of infection Acute Infection AIDS CD 4+ T cells Neutralizing antibodies CTL response Viral load Binding antibodies TIME FROM INFECTION (months – years) Slide provided by N Taylor, HIV/AIDS unit, NICD

Interpretation of results!

Interpretation of results!

Impact of TARV on Viral Load

Impact of TARV on Viral Load

Viral Suppression • Optimal viral suppression is defined generally as a viral load persistently

Viral Suppression • Optimal viral suppression is defined generally as a viral load persistently below the level of detection (HIV RNA <550 copies/m. L) Supressão óptima viral é geralmente definida como uma carga viral persistentemente abaixo do nível de detenção (HIV RNA <550 cópias/ml) • Isolated blips (viral loads transiently detectable at low levels, typically HIV RNA <400 copies/m. L) are not uncommon in successfully treated patients and are not predictive of virologic failure “blip” ou escape viral de vírus sensível isoladas (cargas virais temporalmente detectáveis aos níveis baixcos, tipicamente HIV RNA <400 cópias/ml) não são incomuns em pacientes tratados com sucesso e não são previsíveis a falência virológica

Viral Load Testing Strategy

Viral Load Testing Strategy

Routine Scheduling • After initiation of ART or modification of therapy because of virologic

Routine Scheduling • After initiation of ART or modification of therapy because of virologic failure. – Plasma viral load should be measured 6 months after treatment initiation or modification. – The purpose of the measurements is to confirm an adequate initial virologic response to ART, • indicating appropriate regimen selection and • patient adherence to therapy. – Repeat viral load measurement should be performed at intervals until the level falls below the assay’s limit of detection.

Routine Scheduling • In virologically suppressed patients in whom ART was modified because of

Routine Scheduling • In virologically suppressed patients in whom ART was modified because of drug toxicity or for regimen simplification. – Viral load measurement should be performed after changing therapy. – The purpose of viral load monitoring at this point is to confirm the effectiveness of the new regimen.

Routine Scheduling • In patients on a stable, suppressive ARV regimen. – Viral load

Routine Scheduling • In patients on a stable, suppressive ARV regimen. – Viral load should be repeated every 12 months or as clinically indicated to confirm continuous viral suppression.

Target Scheduling • In patients with suboptimal response. – The frequency of viral load

Target Scheduling • In patients with suboptimal response. – The frequency of viral load monitoring will depend on clinical circumstances, such as adherence and availability of further treatment options. – In addition to viral load monitoring, a number of additional factors, such as patient adherence to prescribed medications, suboptimal drug exposure, or drug interactions, should be assessed. – Patients who fail to achieve viral suppression should undergo resistance testing to aid in the selection of an alternative regimen (see Drug-Resistance Testing and Virologic Failure sections).

Monitoring Schedule Baseline CD 4 Viral Load Follow-Up Before ART Initiation On diagnosis 6

Monitoring Schedule Baseline CD 4 Viral Load Follow-Up Before ART Initiation On diagnosis 6 months At ART After ART Follow-Up Initiation or on Effective Switch ART Yes 6 months 12 months

Adult Monitoring Schedule Controlo Clínico – Laboratorial do adulto após início TARV

Adult Monitoring Schedule Controlo Clínico – Laboratorial do adulto após início TARV

Child monitoring schedule Controlo Clínico – Laboratorial da criança após início TARV

Child monitoring schedule Controlo Clínico – Laboratorial da criança após início TARV

Key points! • Viral load predicts progression of disease in an individual, and onward

Key points! • Viral load predicts progression of disease in an individual, and onward transmission of HIV to sex partners or from mother to baby Carga viral prediz a progressão da doença em uma transmissão individual e transmissão adiante do HIV aos sexo dos parceiros e de mãe ao bebé • In most individuals, viral load will drop to below levels detectable by viral load blood tests after 6 months of ART Na maioria dos indivíduos, a carga viral irá cair dos níveis detectáveis por exames de sangue de carga viral após 6 meses de TARV

Key points! • Viral load testing is the preferred method for detecting treatment failure

Key points! • Viral load testing is the preferred method for detecting treatment failure for ART patients and should be checked after 6 months on ART Teste de carga viral é o método preferido para a detecção de falha de tratamento para pacientes em TARV e devem ser verificados depois de 6 meses em TARV • Viral load <1000 copies/ml indicates acceptable response to ART Carga viral < 1000 cópias/ml indica resposta aceitável para o TARV

Key points! • Virologic treatment failure: persistent (2 or more VL test results >1,

Key points! • Virologic treatment failure: persistent (2 or more VL test results >1, 000 with the initial test being performed >6 months on ART and the 2 nd test performed after adherence counselling and a minimum of 3 months of good adherence) Falha virológica de tratamento: persistente (2 ou mais resultados de teste de CV > 1. 000 com o teste inicial sendo executado > 6 meses em TARV e o 2º teste realizado após aconselhamento de adesão e um mínimo de 3 meses de boa adesão)

Obrigada!

Obrigada!