Terry Marshall: Program Head, NHLS: Comprehensive care, Management and Treatment Program (CCMTP) : HIV and AIDS, SA. Pravi Moodley : Clinical Virologist, NHLS,KZN,SA

SA ANC Data 2006 NDOH,SA 2006 PRAVI MOODLEY DEPT OF VIROLOGY 1/10 South Africa's land surface. 21% of South Africans in KZN NDOH,SA 2006 PRAVI MOODLEY DEPT OF VIROLOGY

SA ANC Data 2006 : Provincial Distribution NDOH,SA 2006 PRAVI MOODLEY DEPT OF VIROLOGY

SA ANC Data 2006 : Age Distribution NDOH,SA 2006 PRAVI MOODLEY DEPT OF VIROLOGY

CD4 ? Viral load PCR Viral Load ? CD-4 PRAVI MOODLEY DEPT OF VIROLOGY

SA CCMTP NHLS EQA Flowcytometry CD-4( Beckman-Coulter, Becton-Dickinson) – NHLS QAD ( Glencross ,NHLS) Quantitative HIV-1 Viral Load ( NASBA, Biomerieux) – QCMD,NEQAS Qualitative DBS HIV-1 DNA ( PCR, Roche) – QCMD,CDC Infant diagnosis < 15 months Piloting National IQC program : Viral Load ,possibly PCR if successful. Terry Marshall, CCMT Program NHLS (2007) PRAVI MOODLEY DEPT OF VIROLOGY

SA National Data: infant diagnosis PCR per month Just look at that! I love this chart! From very few babies accessing HIV related health care services to our performing around 16000 PCR tests per month! And going up all the time. Our antenatal survey shows approximately 30% of pregnant ladies attending the public health services are HIV positive. Our annual birth cohort is probably about 1.4 million now. This implies that approximately 450 000 babies need to be screened each year having been HIV exposed. We need to double the number of specimens sent to the laboratories in order to be comfortable that we are screening our entire exposed birth cohort. As the plan is to expand screening of babies into the EPI clinics with time, this will certainly become increasingly feasible. As can be seen earlier in the presentation, there is sufficient capacity in the NHLS even now to screen all the babies that need it, although we do still intend to expand testing capacity a little further for logistical reasons. Terry Marshall, CCMT Program NHLS (2007) PRAVI MOODLEY DEPT OF VIROLOGY 7

SA National Data: infant diagnosis PCR results Self explanatory! Very good decrease in percentages of HIV positive tests. With the percentages still declining as our PMTCT programme expands! Terry Marshall, CCMT Program NHLS (2007) PRAVI MOODLEY DEPT OF VIROLOGY 8

KZN Data : DBS HIV DNA PCR

Implementation : DBS HIV DNAPCR KZN 2005 Age Distribution of Children Tested PRAVI MOODLEY DEPT OF VIROLOGY SA AIDS,2007

Implementation : DBS HIV DNAPCR KZN 2005 Positive HIV DNA PCR in infants PRAVI MOODLEY DEPT OF VIROLOGY SA AIDS,2007

SA National Data: infant diagnosis PCR per Laboratory Terry Marshall, CCMT Program NHLS (2007) PRAVI MOODLEY DEPT OF VIROLOGY

Data Comparison :% contribution KZN vs SA National PCR test Volume KZN 21% of SA population produces 31% of PCR tests Terry Marshall, CCMT Program NHLS (2007) PRAVI MOODLEY DEPT OF VIROLOGY

SA National Data: monitoring CD-4/ month Dec and Mar/Apr are months with lots of public holidays, hence the decrease in specimen numbers. June 2007 was the HCW strike so these numbers are also less than normal. Otherwise BIG increases from inception of the programme in 2004 until now. Terry Marshall, CCMT Program NHLS (2007) PRAVI MOODLEY DEPT OF VIROLOGY 14

SA National Data : monitoring CD-4 by Category Nice improvement in CD4 tests with the percentage of those below 200 improving. Seemed to level off for a while, but now the curves are diverging again. Contributing factors are healthier HIV positive people entering the service for monitoring, and also those responding well to treatment with improving CD4 counts with time. Terry Marshall, CCMT Program NHLS (2007) PRAVI MOODLEY DEPT OF VIROLOGY 15

KZN Data : monitoring CD-4 Laboratories Jan– June 2008 PRAVI MOODLEY DEPT OF VIROLOGY

Data Comparison :% contribution KZN vs SA National CD-4 test Volume 23% of CD-4 tests come from 21% of SA’s population Terry Marshall, CCMT Program NHLS (2007) PRAVI MOODLEY DEPT OF VIROLOGY

SA National Data : monitoring viral load tests/month As for the CD4 curve Terry Marshall, CCMT Program NHLS (2007) PRAVI MOODLEY DEPT OF VIROLOGY 18

SA National Data : monitoring Viral load volumes per laboratory Terry Marshall, CCMT Program NHLS (2007) PRAVI MOODLEY DEPT OF VIROLOGY

SA National Data : monitoring viral load by Category Bit of a worrying drop in undetectable viral loads, albeit tremendous improvement over the beginning of the programme. I am analysing the data more closely to see whether the problem is new people entering the service and thus diluting the effect of those responding to treatment, and to see whether there might be problem geographical areas in which failure may be occuring. Terry Marshall, CCMT Program NHLS (2007) PRAVI MOODLEY DEPT OF VIROLOGY 20

Data Comparison:% contribution KZN vs National Viral Load test volume 21% of the country produces 30% of the viral load tests. Terry Marshall, CCMT Program NHLS (2007) PRAVI MOODLEY DEPT OF VIROLOGY

KZN Data Viral Load tests per Laboratory Jan – June 2008 PRAVI MOODLEY DEPT OF VIROLOGY

NHLS Laboratory Capacity Support for CCMTP HIV/AIDS,SA SA National Data NHLS Laboratory Capacity Support for CCMTP HIV/AIDS,SA Number of Laboratories Number of Systems Test Capacity Tests per month %Test utilization per month CD-4 56 78 351 000 250 000 71% NASBA Viral load 17 25 108 000 70 000 65% HIV DNA PCR 8 9 35 100 16 500 47% This slide contains information on the numbers of tests that can be worked through conservatively in a month with normal 8 hour working days. The volumes can be increased 2 or 3 fold if extra shifts are worked or 24/7 workdays introduced for these tests. I like to keep the national utilization at below 70% to allow surge capacity and for in case of electricity problems, equipment breakdown, contamination issues etc. Terry Marshall, CCMT Program NHLS (2007) PRAVI MOODLEY DEPT OF VIROLOGY 23

Acknowledgements National Department of Health, South Africa. KwaZulu-Natal Department of Health, South Africa. Global Fund AIDS TB Malaria (GFATM). Absolute Return for Kids (ARK),UK. Italian Co-operation, South Africa UNICEF, South Africa. BMS-Secure the Future. NHLS and our Staff All Our Patients PRAVI MOODLEY DEPT OF VIROLOGY