simplification, cost-reduction strategies and examples from the field

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Simplification, cost-reduction strategies and examples from the field. Teri Roberts Diagnostics Advisor Medecins Sans Frontieres , Access Campaign 7th International AIDS Conference 2 July 2013. - PowerPoint PPT Presentation

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Simplification, cost-reduction strategies and examples from the field

Teri RobertsDiagnostics Advisor Medecins Sans Frontieres, Access Campaign

7th International AIDS Conference 2 July 2013

Virological monitoring detects treatment failure earlier than clinico-immunological monitoring

How viral load testing fits into the package of care to ensure people stay undetectableDrop routine CD4 monitoring for virally suppressed ART treated PLWHA and rather use routine VL monitoring to trigger the need for CD4 testing (is CD4 over 200 cells/ul?)Viremic patients can re-suppress following an adherence intervention

The importance of preserving first line, affordable, robust, one-pill-a-day regimens

Guidelines: required to confirm Tx failure: India, Ukraine LTD availability on the groundGuidelines: required routinely (or if not then at least to confirm Tx failure): Malawi, Mozambique (at 6 months on ART), South Africa, Botswana, Brazil available South Africa, Botwana, Brazil; LTD availability Malawi; not available in Mozambique6

Implementation is done in support of, and in collaboration with, the Ministries of Health and reference laboratories SAMBACAVIDIBIOMERIEUXBIOCENTRICPOC CD4 testing implemented: CAR, Chad, Congo, DRC, Guinea, India, Kenya, Lesotho, Malawi, Mozambique, South Africa, Swaziland (PIMA, but may try new POCs when available).POC VL testing planned to be implemented: Malawi, Uganda (SAMBA) and other countries e.g. South Africa, Swaziland, Lesotho, Malawi, Mozambique, Zim may try new POCs, when available, for EID and/or VL.MSF own VL lab: Malawi (bioMerieux), Myanmar (Cavidi), Swaziland (Biocentric), Zim (bioMerieux)7

Current situation...greatly sped up.8G. Patten et al. Poster TUPDD0106 (Oral abstract session: The point of point of care (Tuesday)) Youth and adolescents have been identified as a particularly vulnerable group, at greater risk of loss from both pre-ART and ART care. MSF supported clinic in Khayelitsha, Cape Town, South Africa: implemented POC CD4-testing at a clinic dedicated to youth aged 12 to 25 years. POC CD4 testing significantly improved assessment for ART eligibility, ensuring that most youth were made aware of their treatment needs on the day of HIV diagnosis.

Does point-of-care (POC) CD4 testing reduce losses from care between HIV diagnosis, assessment for ART eligibility and ART initiation among HIV-positive youth in Khayelitsha, South Africa?

Group A (Before)Group B (After)HIV TestingBlood sample drawn for CD4 countingWHO Staging*ART preparation counselling sessions

ART InitiationCD4 ResultART eligibility assessedVisit 1Visit 2Visit 3Visit 4Visit 5Visit 6HIV TestingBlood sample drawn for CD4 countingWHO StagingART preparation counselling session

ART InitiationCD4 ResultART eligibility assessedVisit 1Visit 2Visit 3Visit 4Visit 544%50%34 days28 daysP=0.6ART eligibility assessment improved (relative risk =2.4 95% CI: 1.8-3.4) The proportion of eligible patients who initiated ART: 44% (lab-based) and 50% (POC) (p=0.6) Of those eligible patients who started ART preparation counseling 81% (lab-based) and 91% (POC) (p=0.2) initiated ART Time between HIV-testing and ART initiation was reduced from 34 to 28 days

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Alternativestest goes closer to the patient.poc and hf. Advantagesno loss between test and result, immediate action possible, motivatesdisadvcost? HR? low throughput..patient still has to travel.11Point-of-care versus laboratory-based tests for viral load testing

Regional-level laboratory tests will use dried blood spot samples that can use finger or heel prick blood

Diagnostic accuracy of DBS using the COBAS Ampliprep/COBAS TaqMan HIV-1 v2.0 (CAP/CTM)

NMRL, Harare, Zimbabwe in collaboration with MSFSekesai Mtapuri-Zinyowera (WEPE610 - Poster Exhibition on Wednesday)118 finger prick DBS, venous blood DBS and plasma specimens from ART patients attending two rural OI clinics in Buhera and Tsholotsho districts and one urban OI clinic in Harare good sensitivity of DBS compared to HIV-1 RNA plasma but very low specificity, which translated in a higher rate of false positive results with DBS at lower VLs ( $157,800 savedEfficiency at 5,000 cps/mL = 51,4% => $283,700 saved

Sample 1500 L

100 LPool 500 LViral load testing100 L100 L100 L100 LSample 2500 LSample 3500 LSample 4 500 LSample 5 500 LWhat to do with pooled results?1. Pooled VL result < threshold => no further testing 2. Pooled VL result > threshold => further testingMSF has previously validated the use of fingerprick DBS on the bioMerieux NucliSENS EasyQ HIV-1 platform, which is RNA-specificReports: www.msfaccess.org/reports

2012IAS poster TUPDD0102 and Oral abstract session: The point of point of care (Tuesday)2013