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

2. 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

3. 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)

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

5. 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

6. 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

7. 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

8. 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)

9. 56-82% documented Enhanced Adherence 23-71% repeat VL taken

10. 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

11. 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

12. Part 2: The laboratory

13. 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

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

15. 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

16. 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

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

18. 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

19. 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

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