Simplification, cost-reduction strategies and examples from the field Teri Roberts Diagnostics Advisor MSF Access Campaign

Virological Monitoring Detects Treatment Failure Early On Adapted from Bartlett et al. Lancet Infect Dis 2009

Across programmes: 2% of treated patients are on 2nd-line ART In South Africa (Khayelitsha), where routine virological monitoring is available: 12% on 2nd-line after 5 years

HIV Policy and Progress Indicators Across 16 Countries CameroonCARDRCEthiopiaGuineaIndia VL for Tx failure OPT NOOPTREQ Routine VLOPTNO AvailableLTD KenyaLesothoMalawiMozambiqueMyanmar VL for Tx failure OPT REQOPT Routine VLNO REQNO AvailableYESLTD NOLTD South AfricaSwazilandUgandaZambiaZimbabwe VL for Tx failure REQOPT Routine VLREQNOOPT NO AvailableYESLTD Lynch et al. Science 2012 OPT: optional; REQ: required; LTD: limited

How to increase access to virological monitoring? Reduce complexity Reduce price – Market entry – Volume – Competition – Open and polyvalent platforms – Price transparency Field validate new and current tests (point of care and lab-based) Perform operational research to define best adapted and most feasible tests for different settings Introduce viral load testing in a phased in approach – Define testing frequency – Replace CD4 monitoring with viral load monitoring – Implement evidence-based algorithms to prioritise patients

Laboratory-based testPoint-of-care test SamplePlasma, DBSFingerstick, heelstick Sample volume 200 – 1000μl≤100μl Sample prepSimple, no contamination Simple, part of POC test ConsumablesMinimal, open accessMinimal (1 lancet, 1 collection tube, 1 cartridge) ReagentsNo cold storage, stable ≥40°C for ≥18 months Part of cartridge, no cold storage, stable ≥40°C for ≥18 months PowerAC and batteryAC, battery (≥8 hours), solar InstrumentOpen access and polyvalent, 1 room, no contamination Closed system, automated, small and lightweight, environmentally robust (heat, humidity, rigorous movement) Hands-on time≤1 hour≤10 minutes Time to result≤1 day≤30 minutes RangeQuantitative, all subtypes, ≥50 copies/ml Quantitative / semi-quantitative, all subtypes, ≥1000 copies/ml Training / skillMediumMinimal, basic (≤2 days), no precision pipetting RegulationWHO PQ (opt CE, FDA) Cost per test≤$10≤$8 Instrument≤$5000 (all required)≤$1000 (single instrument)

Simplifying sample transport by using DBS Quick processing of whole blood Inefficient sample networks Alternative: dried blood spots Long distances, ambient temperature Time to result: e-health, m-health Fingerprick DBS NucliSENS EasyQ® HIV-1 v2.0 viral load test (bioMerieux) for DBS MSF validation of fingerprick DBS in Malawi Other tests for use with DBS?

NucliSENS EasyQ® HIV-1 v2.0 (bioMérieux) Thyolo district hospital, Malawi DBS validated Real time NASBA (isothermal signal amplification), RNA specific Logistical challenges: – laboratory infrastructure – unreliable power supply – unreliable water supply – provision of RNAse-free water – unreliable air-conditioning – non-adherence to cold chain transportation, especially at customs – inability to find local laboratory technicians with molecular biology expertise – lack of in-country trouble-shooting and maintenance services 1. Extraction room 2. Amplification room

Generic HIV viral load assay (Biocentric) Nhlangano health center, Swaziland Open system, low cost Real time RT-PCR (DNA and RNA) Logistical challenges Use of plasma as a sample type (use of DBS is research use only) Most of the other challenges as for the NucliSENS test

ExaVir TM Load Version 3 (Cavidi) Yangon, Myanmar (field site is in Shan state) Subtype independent, relatively low cost, minimal lab requirements, not as prone to contamination and not as dependent on precision pipetting as molecular lab tests ELISA of HIV reverse transcriptase activity Challenges include: Must be performed on plasma Plasma must be frozen at -20°C Need for back-up vacuum pump Relatively low through-put for lab test Good water quality is essential Positive and negative controls must be supplied in-house Sample preparation to isolate the reverse transcriptase enzyme is labour- intensive

For more information, please grab a copy of our viral load report (also available on our website:

Performance evaluation of SAMBA semi-quantitative HIV viral load test for therapy monitoring in resource-poor settings Dr. Suna Balkan MSF Aids Working Group

Scaling-up in the MSF project Chiradzulu district, Malawi Decentralisation Task shiftingNeed for a POC VL

SAMBA system characteristics All HIV1 subtypes & recombinants Threshold 1,000 copies/ml Heat stability at 50°C Robust & simple instrument No or minimum electricity Minimum handling No risk of contamination Turn around time allowing same day result Affordable cost Can detect Groups M, N, O & recombinants Cut-off at 1,000 copies/ml Heat stable reagents; no cold chain transport or storage Isothermal amplification with simple visual detection Low power requirement 350W Preloaded reagents in a closed cartridge Test time = 90 minutes with throughput of 24/day at 6.5 hr working day MSF requirements SAMBA

Visual readout of SAMBA semi-quant VL test <1,000 cp/ml≥1,000 cp/m l

SAMBA system SAMBA-prep (sample extraction) SAMBA-amp (amplification) 1 to 4 samples per run

* Roche TaqMan accuracy: +/- 0.3 Log per package inse rt Evaluation of SAMBA London St Thomas & Royal London Hospitals in 134 clinical samples Concordance between SAMBA & Roche = 97.8 % (131/134) < 500 (<2.7 log) 500 – 2000 ( log)* >2,000 (>3.3 log) Total SAMBA >1, SAMBA < 1, Total (%)95 (71%)4 (3%)35 (26%)134 Roche Taqman v2 (copies/ml)

Malawi – 13.2 million population mainly rural – 1 million HIV-infected MSF project based in a rural district – 1 hospital (laboratory),10 health centres – HIV care in 2000,decentralisation in 2003 – patients followed under ART – 80% followed in the 10 decentralised health centres – Integrated project with MOH MSF Chiradzulu project background

MSF Arua project background Northwestern Uganda Arua + catchment population : 1,5 M HIV prevalence 3% ART project since 2002 Arua District Hospital 7000 patients followed under ART Integrated project with the MOH

SAMBA tested on-site by MSF technician SAMBA tested on-site by MSF technician Roche TaqMan v2 at Royal London Hospital Roche TaqMan v2 at Royal London Hospital Abbott RealTime PCR at Addenbrooke SAMBA field trials in Malawi and Uganda 200 HIV+ patients in Malawi 154 HIV+ patients in Uganda recruited from HIV clinic during routine visit 200 HIV+ patients in Malawi 154 HIV+ patients in Uganda recruited from HIV clinic during routine visit 200 µl fresh plasma Frozen plasma shipped directly Results to MSF Discordant SAMBA/Roche All testing blinded to each other

Malawi results – SAMBA vs Roche TaqMan v2 Viral Load (cp/ml) < 500 (<2.7 log) 500 – 2,000 ( log)* >2,000 (>3.3 log) Total SAMBA >1, SAMBA < 1, Total (%)146 (73%)8 (4%)46 (23%)200 Overall concordance with Roche v2 = 98% (196/200) Roche TaqMan version 2 * Roche TaqMan accuracy is +/- 0.3 Log per package insert

Uganda results – SAMBA vs Roche TaqMan v2 Viral Load (cp/ml) < 500 (<1.7 Log) 500 – 2,000* ( Log) >2,000 >(3.3 Log) Total SAMBA >1,00020*5658 SAMBA < 1,000902*496 Total (%)92 (60%)2 (1%)60 (39%)154 Overall concordance with Roche v2 = 96.1% (148/154) Roche TaqMan v2 * Roche TaqMan is 0.3 Log accuracy (package insert)

Conclusion SAMBA platform is much simpler than currently available molecular technologies which require highly-trained personnel and sophisticated infrastructure only available in centralised laboratories SAMBA device is much easier to handle and being a closed system, prevents contamination by amplicons Staff training requirement for SAMBA is minimal SAMBA can be implemented in lower healthcare levels such as district hospitals or health centres with a basic laboratory but supplied with electricity Routine use of Samba will be now implemented in Arua and Chiradzulu with on going evaluation Will improve HIV care in a decentralization & task shifting strategy

Virological efficacy of ART over time at MSF sites in Arua and Chiradzulu > 65 % of patients on ART have VL < 40 cp/ml after 6 months > 80 % of patients on ART have VL < 1,000 cp/ml after 6 months n = 284

Distribution of viral loads in treated and untreated individuals in Malawi & Uganda 1,000 cp/ml 1x10 5 1x10 4 1x10 3 1x10 2 <100<40 1,000 cp/ml 1x10 5 1x10 4 1x10 3 1x10 2 <100<40 1,000 cp/ml 1x10 5 1x10 4 1x10 3 1x10 2 <100<40 1,000 cp/ml 1x10 5 1x10 4 1x10 3 1x10 2 <100<40