Making Viral Load Routine Implementation experience from MSF Dr Helen Bygrave IAC 2016

Emphasis programmatic / civil society and lab must not act in silos – need to come together for effective scale up Programmatic and Laboratory Must Speak to Each Other www.msfaccess.org/makingviralloadroutine

Sites for Routine VL monitoring 10 ART Programmatic Sites 189,795 Patients on ART 7 + 1 VL Laboratories: 320,000 tests performed Biomerieux Harare NMRL Maputo ( moving to Abbott) Thyolo, Malawi( moved to Abbott) Biocentric Shiselweni , Swaziland Abbott Kinshasa DRC SAMBA 1 Chiradzulu, Malawi Arua, Uganda Xpert HIV-1VL Gutu Zimbabwe Lesotho ( Roma ) Malawi ( Thyolo, Nsanje, Chiradzulu) Mozambique ( Changara , Maputo) Swaziland ( Shiselweni) Uganda ( Arua ) Zimbabwe ( Gutu , Buhera)

MSF experience: Programmatic Strategies: Knowing Your viral load cascade How are we going to get this data ?

VL Cascade VL Coverage % > 1000 copies/ml % receiving Enhanced Adherence Counselling % Getting a repeat VL % with second high VL above threshold switched to second line

32-91% Coverage of Routine Viral Load Health System The Role of lay workers in taking the samples Education of health care workers to recognise value of viral load Setting clear monthly clinic targets for VL Health system strengthening – triage and patient flow – flagging to identify clients in need of VL ( Use of EMRs) 32-91% Coverage of Routine Viral Load

32-91% Coverage of Routine Viral Load Demand Creation from Civil Society : Knowing when VL should be taken What VL means What action needed depending on the result Investing in client education material- Needs funding Will group ART refill strategies such as CAGs and Clubs help? Adherence Clubs: VL uptake 67% v 49% CAGs Mozambique: VL uptake 72%v 47% 32-91% Coverage of Routine Viral Load

Value of a “ Good Result” Qualitative work Swaziland ( Horter et al) Offer Differentiated Care “It encourages me to hold on and take my treatment as prescribed” ( Client Shishelweni Swaziland)

56-82% documented Enhanced Adherence 23-71% repeat VL taken

Health systems strengthening for flagging clients in need of EAC and repeat VL Tools EAC register and High VL form – need funding ? Supervision and mentorship Who’s doing the EAC? 24-50% suppressed after EAC to < 1000 copies/ml

10-68% of those eligible switched to second line ART Access to second line drugs where the patient is Decentralisation Task shifting Remote Switch decision support Apps Sending case summary to district level Perceptions of second line from HCW and Clients 10-68% of those eligible switched to second line ART

Part 2: The laboratory

Is plasma feasible on centralised platforms? Swaziland Experience Seeing ART patients daily but unable to have sample transport daily Trained lay workers to perform phelbotomy and centrifuge samples that are refrigerated at primary care level Reduced sample transport to twice weekly Yes but investment in HR and coordinated sample transport

Strategies that have supported VL scale up Plasma -Near POC SAMBA 1 Xpert HIV -1 VL DBS centralised platform Biomerieux and Abbot

Lessons Learned Setting Up Centralised VL Testing Platforms To purchase or lease Controls costs Flexibility Inclusion of maintenance in cost Possible incentive for better maintenance Infrastructure Adequate space Power / water supply Storage space for consumables Retention of specialised laboratory technicians Development of laboratory information systems for VL: programmed to produce clinically useful lists and triggers WASTE MANAGEMENT No guidance No regulation 10mg cyanide from every kg of VL waste

Lessons Learned Keeping a VL Laboratory Running Power supply : plan for longer UPS Maintenance Training of local staff to perform maintenance Availability of parts in country or regionally All machines underutilised- link between ART programme / VL cascade data and VL scale up planning HR management : Setting clear targets for throughput

Back Up Planning Must be Part of the Plan In or out of country : Public or private

Experience with Near Point of Care Allows task shifting for sample processing ( Study Chiradzulu – excellent concordance of results lay worker v lab technician) SAMBA 1 ( Malawi / Uganda ) 80% of clients received results on the same day Xpert – polyvalency – Study in Zimbabwe concurrent testing of VL , EID , TB , HPV on same platform in same clinic Simpler to set up Down time much less – modular repairs Lower Error rates

Some Questions Going Forward How do we best use centralised, near POC and true POC Coordination of donors across programmatic and laboratory needs Funding of layworkers crucial to coverage of VL and provision of enhanced adherence Access to timely second line switch ; and perceptions of second line therapy

Thanks to All the MSF Field Teams Collaborating Ministries of Health People Living with HIV in the MSF supported projects UNITAID