Scaling Up Retinal Screeningin an HIV clinic in Nanning, China

to prevent blindness from CMV retinitis

Peter Saranchuk, MDTB-HIV Adviser

Southern Africa Medical Unit (SAMU)Operational Centre Brussels (OCB)

Médecins Sans Frontières (MSF)

Advances and Opportunities to Address CMV retinitisSatellite SymposiumIAS Conference30 June 2013

HIV late presenters

31.8%

Of people present for the first time with a CD4 count < 200 cells/µL

CMV: The 3rd most common/serious OI

Prior to Nov 2008 in Nanning

Problem: Diagnosis of CMV usually delayed

– Retinal screening not done– Diagnosis made only after vision loss had

already occurred– Irreversible– Required referral to a secondary hospital

Poor Outcomes (prior to Nov 2008)

• Of 17 patients assessed in Nov 2008 and found to have active or inactive CMV retinitis:– 5 (29%) had bilateral involvement– 7/11 eyes (64%) with inactive disease were

blind*

* <20/400 visual acuity and/or able to count fingers at 10 feet

Solution

Training in retinal examination

•

Over 4days

• By an ophthalmologist (D. Heiden)• Of HIV clinicians• In the use of an indirect ophthalmoscope (IO)• E-mail address given for follow-up support

Ophthalmoscopy

The key to both = use dilating drops

IndirectDirec

tVs.

After Nov 2008 in Nanning

•Retinal screening–Performed routinely– In all at-risk patients (e.g. those with CD4<100)– By HIV clinicians– Using an indirect ophthalmoscope– In the HIV clinic

CMV retinitis has a typical pattern

After Nov 2008

• Now able to diagnose CMV retinitis:– At the first visit– Within minutes– Inexpensively– At primary HIV care level– More easily than other common, serious OIs!

After Nov 2008

• Now able to diagnose CMV retinitis:– At the first visit– Within minutes– Inexpensively– At primary HIV care level– More easily than other common, serious OIs!

•= A point-of-care diagnostic!

Every HIV clinic should have…

• A bottle of drops to dilate pupils• E.g. Tropicamide

Ophthalmologists still involved

• Telemedicine– E-mailing of digital retinal images

• Complicated cases– Immune Recovery Uveitis (I.e. IRIS)– Retinal detachment

After Nov 2008• Routine retinal screening• Earlier diagnosis• Earlier treatment • Improved visual outcomes

– E.g. Minority of patients now being diagnosed with CMV retinitis are blind

Subsequent Trainings

Average duration of treatment in Nanning

~4.5 months

N.B.: ART needs to be initiated as soon as possible

Usual Treatment: Sticking needles into eyes!

Price of valganciclovir needs to be…

<1 dollar per tablet

to prevent CMV-related blindnessand encourage retinal screening

Conclusions1. Retinal screening performed routinely

prevents CMV-related blindness2. Can be done by trained HIV clinicians

– In resource-limited settings3. Diagnosis of CMV retinitis then becomes

easier than other OIs!4. Need a treatment which is both

convenient and affordable

Acknowledgments

• Dr. David Heiden• Pacific Vision Foundation• Seva Foundation• Chinese partners

–Guangxi CDC–The Fourth Hospital of Nanning

Treatment options in Nanning

• Intravitreal injections (weekly)– Inexpensive– Barbaric!

• I.v. ganciclovir (daily)– Expensive– Inpatient vs. outpatient?

• Oral valganciclovir (VG)– Convenient– Outrageously expensive (~40 USD per tablet)