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The role of virological monitoring A clinical perspective

The role of virological monitoring A clinical perspective . Eric Goemaere MSF South Africa . Treatment simplification? . Simplified treatment . PHC decentralization . Task shifting . HIV/TB integration .

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The role of virological monitoring A clinical perspective

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  1. The role of virological monitoring A clinical perspective Eric Goemaere MSF South Africa

  2. Treatment simplification? Simplified treatment PHC decentralization Task shifting HIV/TB integration

  3. Impact of routine monitoring <> Immuno-clinical monitoring on regimen change

  4. VL monitoring in LIC : a love/hate story More accurate assessment of treatment failure will reduce the delay in switching to second-line drugs. Targeted use of VL can limit unnecessary switching and routine use of VL can reduce the risk of resistance. WHO 2010 guidelines HIV Viral Load Monitoring in Resource-Limited Regions: Optional or Necessary? Alexandra Calmy,1,5 Nathan Ford,6 Bernard Hirschel,2 Steven J. Reynolds,7 Lut Lynen,4 Eric Goemaere,8 Felipe Garcia de la Vega,1Luc Perrin,3 and William Rodriguez9,10, CID 2007:44 Keiser et al, AIDS 2011

  5. Exclusive Immuno/clinical monitoring delays clinical reaction Female, CHK Kinsahsa N° 040025, DOB 11/10/1972 Cd4 < 50 % Cd4 < 30 % VL14.000 Phase IV Oesophageal candidiasis VL13.000 -> moved to 2nd line

  6. Predicting virological failure ( < 30 % of nadir CD4) in adults Sensitivity = 17.2% (12.3% - 23.0%) Specificity = 94.5% (93.6% - 95.3%) PPV = 18.5% (13.3% - 24.8%) NPV = 94.0% (93.1% - 94.9%) M. Pujades, L. Pinoges , Epicentre, not published

  7. Predicting virological failure in children • Thailand: US IF criteria to identify children with single viral load >1000 copies/ml after 1 year of treatment (n=202) • Sensitivity: 15%; PPV: 16% (Jittamala et al. 2009) • Uganda: WHO IF criteria to identify children with confirmed viral load >400 copies/ml for (n=116) • Sensitivity: 0% (Ruel et al. 2010) • South Africa : criteria to identify children with VL > 1000 cp/ml ( n = 2543 ) • Sensitivity 5 % , PPV= 42 % ( Mary Ann Davies, Durban Aids conference June 2011)

  8. Impact in early detection of VF VL3 group : 22% less likely to experience subsequent virological failure, 27% less likely to be later switched to second line regimen Viral load at 3 months after initiation of antiretroviral therapy is associated with better virological and treatment outcomes than at 6 months. B. Kerschberger1, A. M. Boulle2, K. Kranzer3, K. Hilderbrand1,2, M. Schomaker2, D.Coetzee2, E.Goemaere4, N. Ford2,5, G. Van Cutsem1,2

  9. If no access to VL, priorities for VL ? Steven Van Den Broucke, Sandra Simons, Katharina KranzerDhodhoMunyaradzi, Carol Metcalf, KwenzakwenkosiNcube, Helen BygravePoster : THPE725 Thursday 26th

  10. Impact of late viraemia detection on horizontal and vertical transmission ? Pre-ART Facility based HCT : • Horizontal transmission • Vertical transmission • PMTCT B + : danger for subsequent pregnancies HIV (+): Enrolled in care: ART: RIC @ 12 M** Undetect@ 6 M Out of facility HCT : LTF: LTF: LTF: LTF:

  11. Impact of late viraemia detection on resistance building ( TAM and K65R) Source : The public health approach to identify antiretroviral therapy failure: high-level nucleoside reverse transcriptase inhibitor resistance among Malawians failing first-line antiretroviral, Therapy, Mina C. Hosseinipour& all, AIDS 23:1127–1134

  12. Conclusions Immuno/clinical monitoring do not replace virological monitoring Key challenges are around technical/ geographical / financial access to virological monitoring Unitaid/ Chai/Unicef / MSF concerted efforts will work on all 3 aspects to make virological monitoring a reality in LIC by 2015

  13. Acknowledgements • MSF & MOH teams in Zimbabwe , RDC and South Africa • Helen Bygrave, Teri Roberts ,Nathan Ford • All the ones fighting to be ‘ viral load undetectable’

  14. Thank You

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