Presented to the AIDS 2016 Conference Integrating Cryptococcal Screening into HIV care: The Namibian story Ministry of Health and Social Services Namibia Francina Tjituka: Chief Health Program Officer National HIV/AIDS, Hepatitis and STI Control Program Presented to the AIDS 2016 Conference

Presentation Outline Background Cryptococcus sero-prevalence in Namibia Highlights of Namibia 2014 ART Guidelines Current Cryptococcal Screening Practices Summary Questions and Discussion

Background Namibia Population 2.2m Adult HIV prevalence 14% Slide 3 Namibia Population 2.2m Adult HIV prevalence 14% Estimated 230 000 PLHIV About 12% of patients initiating ART in Namibia have CD4 count < 100 cells/µL Results of the 2014 Laboratory-based Crypto Prevalence Study among PLHIV in Namibia CrAg prevalence 3.3% overall 3.9% for CD4+ counts of CD4+<100 cells/µL 2.3% for CD4+ counts of 100-200 cells/µL

Source. Meditech: NIP Crypto Screening Program Data (2015) Namibia: High-Prevalence Regions CrAg Prevalence per Region, June 2014-May 2015 Source. Meditech: NIP Crypto Screening Program Data (2015)

2014 Namibia ART Guidelines (1) With the right amount of political will and capacity, life-saving intervention can be implemented swiftly and with marginal effort by and burden on the health system. Emphasize that the numbers

2014 Namibia ART Guidelines (2) With the right amount of political will and capacity, life-saving intervention can be implemented swiftly and with marginal effort by and burden on the health system. Emphasize that the numbers

Laboratory Infrastructure 40 laboratories operated by the National Institute of Pathology (NIP) 28/40 labs provide CD4 testing services. 9/28 labs use flow cytometry to conduct CD4 testing 19 have very low volume and use PIMA machines to conduct CD4 testing. ~15 labs started conducting reflexive laboratory-based screening for all samples with CD4<100 cells/µL in June 2014. 60-70% of all CD4 counts done in the country are being done in the 15 labs that are conducting CrAg screening, We estimate that 60-70% of patients with CD4<100 cells/µL have access to CrAg screening.

Current Namibia Institute of Pathology (NIP) Laboratory Reflex Screening then or + STEP 1 STEP 2 STEP 3 Blood collected at initial patients visit CD4 + CrAg testing on samples with CD4<100 Treatment decisions taken at first follow-up visit

Access to CrAg reflexive screening: CrAg Screening in Namibia - Currently Access to CrAg reflexive screening: ~70% Susceptible population: ART initiators with CD<100 ART defaulters with CD4<100 Able to access CrAg screening through clinician-initiated request for CrAg screening

Assessment of laboratory-based CD4 sites Observations: Every eligible sample received is screened for CrAg Lab results posted to Laboratory Information System (MEDITECH) within 24 hours Challenges: Little control over whether results are received and used by sites Laboratory-based

Assessment of sites using PIMA CD4 Observations: Most providers aware of CrAg screening, but do not always remember to send samples for CrAg after seeing a PIMA CD4<100 Results posted within 24hrs of samples being sent for CrAg, but facility staff often do not review CrAg result until next patient visit Equipment failure may delay results (SMS printers, MEDITECH portals) Facilities without doctors on staff do not have access to fluconazole to begin treatment PIMA at Point of Care

Availability of fluconazole and other antifungals Fluconazole was available in the country through the Diflucan Partnership Program until approximately 2013 Since 2013 MoHSS has been purchasing generic fluconazole Fluconazole is part of the Namibian Essential Medicines (NEMs) list Currently classified as an “AB” drug, Means that it can only be prescribed by a medical officer or a specialist Amphotericin B is available in hospitals 5-Fluorocytosine (5-FC) is not on the essential medicines list and is not available in the country.

Summary Namibia has successfully integrated Creptococcal screening into HIV care Recommendations included in the national guidelines in January 2014 The biggest NIP laboratories initiated reflexive CrAg screening on all CD4 specimens <100 cells/mm3 in June 2014. An estimated 70% of patients with CD4<100 cells/mm3 have access to CrAg testing through the NIP Lab-based reflexive program.

Acknowledgements Ministry of Health and Social Services (MoHSS) Namibia Institute of Pathology (NIP) President’s Emergency Plan for AIDS Relief (PEPFAR). Centers for Disease Control and Prevention (CDC) CDC Namibia Office CDC Atlanta: Mycotic Division

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