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Perspectives from MSF’s AHD programmes in Africa: Challenges, lessons, and opportunities

Perspectives from MSF’s AHD programmes in Africa: Challenges, lessons, and opportunities. Tom Ellman MSF SA IAS 2019. Conflicts of Interest. No conflicts of interest to declare. ‘Stable’ / ‘Unstable’ Continuum. Virally undetectable Poorly adherent High Viral load Drug Resistance

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Perspectives from MSF’s AHD programmes in Africa: Challenges, lessons, and opportunities

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  1. Perspectives from MSF’s AHD programmes in Africa: Challenges, lessons, and opportunities Tom Ellman MSF SA IAS 2019

  2. Conflicts of Interest No conflicts of interest to declare

  3. ‘Stable’ / ‘Unstable’ Continuum • Virally undetectable • Poorly adherent • High Viral load • Drug Resistance • Severe immuno-suppression • Opportunistic infection • Critical illness

  4. ….. ART is not a one-way trip to success Inpatient mortality: ~25- 35 % ( amongst them 30% < 48 hrs) Post discharge mortality: up to 20 %

  5. TreatmentfailureVL≥ 1 000 copies/ml and dual class drugresistance Kenya DRC VL ≥ 1 000 copies/ml and CD4 < 100 cells/µL CD4 < 100 cells/µL CD4 < 50 cells/µL All patients VL ≥ 1000 copies/ml

  6. What packages at which level of care?

  7. @Hospital • Rapid Assessment Unit (RAU) • Investment in laboratory and emergency room • Triage for danger signs • Treatment plan initiation in first 24 hours • PoC Viral load and Rapid 2nd line switch • Post-discharge follow-up

  8. @Primary Care Clinic • Triage for danger signs • Detection of advanced HIV in ambulatory patient • Do not rely on clinical skills alone • ART treatment history • ‘Welcome back’ • Critical role of rapid CD4 • AHD Package • Reflex CRAG, LAM +- Xpert • 2nd line switch, rapid ART and TB, crypto treatment? • TPT (QTIB or 3HP?), CTX, Fluconazole • Targetted counselling and tracing (not chasing)

  9. Omega Visitect CD4 LFA • Study in Kinshasa CHK Hospital, OPD and IPD • 475 patients to date • 95% sensitivity and 70-80% specificity • User perspectives • Difficult to manage the incubation times whilst multi-tasking • Possibilities of putting the wrong buffer into the wrong well • Difficulty of incorrectly interpreting the results

  10. PHC level: Advanced HIV Disease screening package ( CD4< 200 and/or symptomatic) Urine Lam (25mins) PIMA (25mins) GeneXpert: HIV VL, MTB/Rif Visitect (40mins) CrAg (10mins) In the near future: FujiFilm LAM, Semi-Quant CrAg, HIV POC ARV levels, HIV POC Genotyping

  11. Case study : Immy CrAg test • A CD4 test must be done first to trigger CrAg test (if CD4<200) • For best results, this test requires that venous blood (EDTA) is first let to stand verticaly for a minimum of 10mins so that plasma can be collected after red-blood cells sediment naturally (as there are no centrifuges in many PHCs). Serum and CSF can be used. Whole blood can also sometimes be used. • Exactly 40ul of plasma is must be pipetted into a reaction tube and a 10min incubation before reading results • For a busy PHC, these steps could have a knock-on effect on the workload of HCW who also need to also multi-task Allow an incubation time of 10 min before reading result Add one drop of CrAg specimen diluent into the labeled cryovial tube Insert one CrAg test strip into the mixture. Add 40µl of plasma sample into the cryovial tube and mix.

  12. Case Study 2: TB LAM (and FujiFilmTB LAM) • TB LAM: The simplest of the POCs but still needs watching • Fujifilm: More complex

  13. Case study 3: Visitect Omega CD4 LFA • The test has 3 incubation steps which need accurate timings • This may prove difficult for clinicians who need to also multi-task Results 30 µL of sample 1 drop Well A 3 drops Well B 90° 90° 1 drop Capillary Wait 20 min Wait 17 min Wait 3 min Venous (EDTA) 3 drops Results in ~40min

  14. These test represent a major burden • Risk of underuse of tests, unreliability of results, delayed responses unless extra capacity and support • Challenge of motivating and capacitating staff • Especially where guidelines and policies are lacking • Do we need specific cadres responsible for POC activities at PHC?

  15. Realising the potential of POC tests Khayelitsha

  16. @Community level • Demand creation • Treatment literacy, • Viral load • AIDS and Advanced HIV Disease • Stock-out monitoring and resolution • Stigma reduction • Social media, apps, and innovative HP approaches

  17. Summary • Practice is far behind Guidelines and Policies • AHD Dashboard in development • Access to essential diagnostic, preventive and treatment tools • Critical gap in 2nd line and cryptococcal meningitis treatments • DSD needed for advanced HIV at all levels of care • Focus on ambulatory at PHC level • Funding and political commitment missing • Community awareness and activism needed

  18. Acknowledgements: MSF and MoH staff, partners, and patients who did all the workMSF and Epicentre colleagues Thank you https://samumsf.org/en/news/advanced-hiv-disease-toolkit

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