#AIDS2016 ASSESSMENT OF THE WORLD HEALTH ORGANIZATION EARLY WARNING INDICATORS OF HIV DRUG RESISTANCE IN NAMIBIA FOR PUBLIC HEALTH ACTION, 2015 Nicholus Mutenda 1, Tuli Nakanyala 1, Ndapewa Hamunime 1, Tadesse Mekonen 1, Francina Tjituka 1, Salomo Natanael 1, Greatjoy Mazibuko 2, Samson Mwinga 2, David Mabirizi 3, Evans Sagwa 2, Helena Walkowiak 4, Alexandra Kiesling 5, Samuel Aptekar 5, Michael R. Jordan 5,6, Steven Y. Hong 5,6 1 Directorate of Special Programmes, Republic of Namibia Ministry of Health and Social Services, Windhoek, Namibia, 2 Systems for Improved Access to Pharmaceuticals and Services program, Management Sciences for Health, Windhoek, Namibia, 3 Systems for Improved Access to Pharmaceuticals and Services program, Management Sciences for Health, Arlington, USA, 4 Systems for Improved Access to Pharmaceuticals and Services program, Management Sciences for Health, New York USA, 5 Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, USA, 6 Division of Geographic Medicine and Infectious Diseases, Tufts Medical Center, Boston, USA Abstract no. TUPDB0101

#AIDS2016 Background Early warning indicators (EWIs) of HIV drug resistance (HIVDR) – foundational element of the World Health Organization (WHO) public health strategy to minimize and monitor emergence of HIVDR in countries rapidly scaling up antiretroviral treatment (ART) – site-specific, quality-of-care indicators that assess factors associated with virological failure and emergence of HIVDR – identify gaps in service delivery for which corrective action can be taken at the ART site or program level – provide necessary program context for interpretation of WHO surveys of HIVDR – should be monitored annually at all treatment sites and integrated into ART program M&E and continuous quality improvement initiatives Namibia has instituted a routine EWI monitoring system and developed HIVDR survey strategies

#AIDS2016 Methods In 2015, Namibia abstracted the following WHO EWIs: – On-time Pill Pick-up – Retention in Care at 12 months – Pharmacy Stock-outs – Dispensing Practices – Viral Load Suppression at 12 months – Viral Load Completion at 12 months EWIs abstracted from adult and paediatric patients from all ART sites in the state health sector: 50 main ART sites and 163 outreach points WHO-recommended definitions and targets used, based on three classifications: – green (excellent performance, achieving desired level) – amber (fair performance, not yet at desired level) – red (poor performance, below desired level) – grey (insufficient data)

#AIDS2016 Geospatial location of 213 ART sites for EWI monitoring, 2015

#AIDS2016 Results On-time Pill Pick-up: – Adults: 45% of sites (excellent >90% or fair 80-90%) – Children: 40% of sites Retention in Care at 12 months – Adults: 54% of sites (excellent >85% or fair 75-85%) – Children: 38% of sites Pharmacy Stock-outs – Adults: 5% of sites (excellent 100% of months with no stock-outs) – Children: 14% of sites Dispensing Practices – Adults: 97% of sites (excellent 0% mono- or dual-therapy) – Children: 91% of sites Viral Load Suppression at 12 months – Low rates of Viral Load Completion among patients eligible for routine viral load testing significantly affected monitoring of Viral Load Suppression

#AIDS2016 Conclusion Namibia has successfully institutionalized EWI monitoring into routine ART program functioning Strengthening patient adherence, retention in care, and ensuring the continuous availability of ART medicines are all high priorities to minimize emergence of HIVDR and achieve the (HIV epidemic control) goals Improving routine viral load monitoring and data capturing is a priority to enable monitoring of viral load suppression rates As a result of these data, program leaders and healthcare providers in regions throughout the country are implementing service quality improvement projects and operational research to improve patient care and minimize the emergence of HIVDR