The role of virological monitoring a clinical perspective
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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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The role of virological monitoring a clinical perspective

The role of virological monitoring A clinical perspective

Eric Goemaere

MSF South Africa


Treatment simplification

Treatment simplification?

Simplified treatment

PHC decentralization

Task shifting

HIV/TB integration


The role of virological monitoring a clinical perspective

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


Vl monitoring in lic a love hate story

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


Exclusive immuno clinical monitoring delays clinical reaction

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


The role of virological monitoring a clinical perspective

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


Predicting virological failure in children

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)


Impact in early detection of vf

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


If no access to vl priorities for vl

If no access to VL, priorities for VL ?

Steven Van Den Broucke, Sandra Simons, Katharina KranzerDhodhoMunyaradzi, Carol Metcalf, KwenzakwenkosiNcube, Helen BygravePoster : THPE725 Thursday 26th


Impact of late viraemia detection on horizontal and vertical transmission

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:


Impact of late viraemia detection on resistance building tam and k65r

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


Conclusions

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


Acknowledgements

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’


The role of virological monitoring a clinical perspective

Thank You


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