Presentation Transcript

1. Implementation of HIV Treatment Monitoring in Lesotho

   Dr. Mphu Ramatlapeng International AIDS Society Conference July 2012 Washington, DC
2. Lesotho at a Glance
3. Lesotho currently has the third-highest HIV prevalence globally, following only Botswana and Swaziland Source: CIA World Factbook, 2011 UNICEF, Country Reports, 2010. World Health Organization: Human Resources for Health 2007. WHO/UNAIDS: 2008 Global Report on the AIDS Pandemic
4. Lesotho has been an early adopter of initiatives in part because of its small size and the existence of political will to innovate 2004 2005 2006 2007 2008 2009 2010 2011 Early infant diagnosis testing Nurse-centric model for ART provision Early infant diagnosis toll free hotline Riders for Health motorbike-based sample / result transportation Queen Mamohato Hospital opens Know Your Status campaign Free access to primary health care Point of care CD4 technology Pediatric HIV/AIDS services Laboratory mentorship program Nursing initiative Clinical mentorship program Decentralization strategic plan Indicates successful Global Fund application year.
5. The number of HIV-exposed-infants tested has increased; despite progress, more work remains around timely Early Infant Diagnosis Approximately 15,200 HEI are born annually A toll free hotline enables expedited communication of test results POC EID technology is expected to be available in the next 1-2 years HEI tested by 2 months % of HEI tested between 0-62 days Note: Age group is defined as <14 yrs and >14 yrs Source: MOHSW DNA PCR Database. Note: Total HEIs per quarter estimated at 3,800. Age at testing data not available before 2009
6. As the number of patients eligible for ART increases, the relative share of those on treatment has continued to increase ←Total ART Need 81,270 3,520 105,635 5,760 111,000 8,000 115,000 23,000 115,000 23,000 According to the MOHSW, as of March 2012, 55.4% of ART-eligible patients are enrolled in ART care 96% 47% 30% 5% LEGEND 226% 35% 20% 15% Need but Not on ART Achieving parity with adult ART coverage Revisions to estimated number of children with HIV (12,000 to 37,000) Pediatric ART absolute numbers increasing at faster rate than adult ART absolute numbers Adults on ART Peds on ART Degree of Parity Source: Annual Joint Review, MOHSW Data Note: Ministry of Health’s stated ART coverage target was 80% by 2010. 2011 need is assumed to be 115,000 for adults and 23,000 for children (official 2011 need figures not yet available)
7. Interventions to address geographical challenges have improved monitoring processes across Lesotho Given Lesotho’s terrain, loss-to-follow-up and turn-around-time are critical roadblocks to the success of the HIV program. These interventions have helped mitigate geographical challenges. Riders for Health Since 2008, clinics in all ten districts have relied on Riders for Health to deliver samples and results to centrally located laboratories Before Riders, 44% of health facilities sent patient samples to the lab every week on average. With Riders, 100% of facilities receive weekly visits to collect samples and return results Riders sample couriers collectively transport over 2,800 samples and 2,000 results each week across the country Point of care expansion Hemocue machines can be found in at least 125 out of 200 clinics Almost all health clinics in Lesotho now perform rapid-result HIV tests 21 active PIMA units are currently found full or part time in 28 clinics, providing CD4 results to patients in 20 minutes Source: Riders for Health Impact Report, Lesotho. 2012.
8. Current plans exist to bring viral load testing in-country and provide access to more clinics Historically Current Status Way Forward One unit acquired and placed at Baylor Clinical Center of Excellence in Maseru At least three technicians were provided with basic training Build local capacity to bring viral load testing in-country Train more clinicians in use of viral load testing Routine viral load testing provided to shift patients onto second line drugs, as necessary All viral load testing for patients suspected of first-line ART failure outsourced to South Africa
9. Sample Viral Load Utilization Guidelines Fall of CD4 count to pre-therapy baseline (or below); or 50% fall from the on-treatment peak value (if known); or Persistent CD4 levels below 100 cells/MM Treatment failure suspected based on clinical grounds – immunological test ordered Adherence counseling Fall of CD4 count to pre-therapy baseline (or below); or 50% fall from the on-treatment peak value (if known); or Persistent CD4 levels below 100 cells/MM Treatment failure suspected based on clinical grounds – immunological test ordered Order viral load test Viral load of >10,000 copies/mL Adherence counseling Order viral load test to inform treatment switching decision Viral load of >10,000 copies/mL
10. Conclusions Given the HIV burden and its relatively small geographical size, Lesotho could serve as a pilot country for viral load testing and potential scale up. As testing volumes increase worldwide, prices continue to fall In 2011, VL testing was 15.9m and is projected to be approximately 36.8m by 2020, driven mostly by rising demand in low and middle income countries Pricing Use of dried blood samples (DBS) makes VL testing easier to deploy Technological advancements now allow for EID and VL to be tested on the same platform, optimizing available capacity and reducing overhead costs Capacity Reduced prevalence of MDR HIV since VL is an earlier indicator of treatment failure than CD4 Anticipated improved patient survival Impact
11. Thank you!