HIV Drug Resistance Transmission Surveys in Malawi

1. HIV Drug Resistance Transmission Surveys in Malawi The 2nd Global HIV/AIDS Surveillance Meeting:- Bangkok 2nd -5th March 2009 Dr. Nellie Wadonda-Kabondo

2. Background • Threshold (Transmission) surveys assess levels of acquired HIV drug resistance strains in specified geographical area • Adapted WHO protocol • Uses plausible markers for new infections • Requires a sample size of 47 clients as per WHO guidelines • First threshold survey in Malawi was conducted in Lilongwe in 2006 • at 3 clinics and recruited 58 clients • The results indicated HIV drug resistance level of < 5%

3. Selection of sites of the 2008-2009 Threshold survey • Survey was repeated in the 3 clinics in Lilongwe • But Lilongwe is treated as one site • After assessing several other sites, Blantyre qualified to be additional site • Lilongwe and Blantyre were selected because ARV services were first introduced in these cities. • Both cities have provided ART services for over 4 years

4. Threshold survey Criteria Consecutive sampling of women attending PMTCT services who meet the following criteria: • Positive HIV test result, • No previous positive HIV test • Aged < twenty-five years • no previous pregnancy • No known exposure to antiretroviral drugs • No known AIDS-defining illness • Not eligible to start ART Residual blood from CD4 counts in PMTCT services was used to prepare DBS samples for TS in both cities

5. Threshold survey Implementation in Blantyre • Before starting implementation of the survey we assessed the sites • Assessment of PMTCT clinics in Blantyre revealed that no site could qualify either because: • There were no clinics that offered CD4 services to all clients from which residual blood could be used or • The site did not see reasonable number of clients who could qualify for the Threshold survey • Thus CD4 testing service for all positive women in the PMTCT program was introduced at two health centres Limbe and Ndirande • this is in line with government policy

6. The CD4 count System in Blantyre • A courier service was set up: • DHO provided motorcycle • health assistant surveillance officers to collect samples from clinics to the laboratory at QECH • Epidemiology Unit provided fuel • The Epidemiology Unit is committed to support the courier service until the DHO takes over in the next year • After four weeks the CD4 system was assessed and was found to be working well • Threshold survey was introduced in December 2008

7. Threshold survey Implementation in Blantyre • For every patient who qualified for TS, the clinicians ordered DBS preparation in addition to CD4 count on the laboratory request form • At intervals, central supervision team checked PMTCT records at the clinic against lab records in terms of: • How many eligible clients visited the clinic, • How many were identified • How many requests for TS DBS did the clinic make, • How many were eligible requests • How many DBS samples were prepared for TS • The last supervision done in February indicated a possibility that some of the request have been missed

8. Eligible clients VS. # DBS samples

9. What next for Blantyre • We are in the process of verifying what happened to Limbe samples • Unfortunately the clinics stopped recruiting after total of 60 requests were made

10. So what has been the Impact of TS on PMTCT program in Blantyre • The courier service that was introduced was found to be: • Working effectively • Cheap as it used available resources • DHO is planning to extend the system to other facilities and integrate other samples in the collection • The two facilities reported that number of women qualifying for ART has increased thereby improving quality of care given to the women • HIVDR related activities continues to improve quality of associated services in the delivery of ART services

11. Threshold survey Implementation in Lilongwe • Survey repeated in the 2006 three sites; Bwaila hospital, Area 25 and Kawale health centres • Started on 13th October 2008. • Survey Implementation has been difficult with a lot of eligible clients being missed, either because: • Eligible clients not being identified by clinic staff • Clients identified but lab request forms not filled or not properly filled • Laboratory not identifying request for DBS • Lab identifying the request but forgetting to prepare the DBS

12. Attempted solutions • Feed back to sites and to the laboratory • Telephone system (air time procured for sites to call the laboratory if client was identified) • Twice weekly supervision visits/ unfortunately not consistent

13. Progress • By 9th January, 62 eligible clients had visited the sites • 56 had been identified by the clinics and DBS requested • 40 DBS samples had been prepared • 22 missed, consecutive sampling not followed

14. Progress by site

15. Way forward for Lilongwe • Survey still going on with the hope that there will be a time period where at least 47 samples will be consecutively identified by at least 1 site • Selected individuals have been promised bonus if no samples are missed

16. Conclusion • Consecutive sampling was broken for all sites in Lilongwe • In Blantyre verification process still going on. • In future TS will be integrated with ANC sentinel surveillance to avoid these challenges

17. Acknowledments • HIVDR work in Malawi is funded by the World Health Organisation and Centres for Disease Control • HIV Drug Resistance Task Force • Ministry of Health • Community Health Sciences Unit • HIV and AIDS Unit • World Health Organization • US Centers for Disease Control and Prevention, Malawi and Atlanta • Lighthouse Trust • Malawi College of Medicine • MSF France • University of North Carolina