1. The Changing Face of Advanced Disease
The Changing Face of Advanced Disease Eric Goemaere, MD, DTMH,PHD Southern African MSF medical unit School of public health , UCT

2. Ongoing late presenters despite increasing median CD4 at initiation
Ongoing late presenters despite increasing median CD4 at initiation . Western Cape , South Africa
Community CD4 count as a marker of morbidity potential: Results from the Western Cape, South Africa. M. Osler, A.Boulle, UCT

3. ART treatment cascade 3 Front doors Side doors Drop-out re-initiating1
PITC
Linkage to Care
Retention in care
Community testing
Undetect. CV
Symptomatic présentation 2

4. Evolution of late presenters ratio (CD4< 100) Health centers levels in 3 capital cities
Kinshasa – 6 facilities
9179 ever initiated – low prevalence
Conakry- 5 facilities – 6553 ever initiated – low prevalence
Maputo – 5 facilities – ever initiated -high prevalence
Source : Tier.net monitoring, Cider, UCT, Katherine Hilderbrand

5. N= 609 HIV-positive admissions ART status : - naïve: 35.7%,
HIV-Related Medical Admissions into Cape Town District Hospital Graeme Meintjes and all, Medicine Volume 94, Number 50, December 2015
N= 609 HIV-positive admissions
ART status :
- naïve: 35.7%,
- current:45.0%
- interrupted :19.3%.
Most frequent primary clinical diagnoses:
TB ( 33.5%),
Other bacterial infection (17.1%),
Other AIDS-defining illnesses ( 10.9%).
By 90 days follow-up, 29.9% required readmission and 13.3% died.
Commonest causes of death: TB (37.2%)

6. Late presenters in 2 Kinshasa Hospitals Maria Mashako, ITM
Variables
CHK, N=1285
n (%)
HGR RB, N=495
Age (years)
39 [32- 46]
39 [32- 47]
Median CD4
76 [24-77]
68 [ ]
ART experienced
ART Naive
994 (77.4)
291 (22.6)
252 (50.9)
243 (49.1)
ART (months)
74 [47-98]
73 [48- 97]
Mortality
124 (25.1)
Hospital stay ( days)
4 [2- 8]
4 [2- 9]

7. Morbidity /Mortality Kinshasa CHK K.Hilderbrand Jan-Jun 2014 n= 1275
Alterated consciousness + headaches
TB: 15 %
Other 4 %
Toxo: 12 %
Causes of deaths 2011
Malaria: 7 %
Crypto meningitis : 56 %
Bacterial meningitis : 6 %
75/952 CRAG (+) or 7.8 %
Cough + fever
Source: annual report , CHK, 2011

8. 10 years of MSF intensive presence
Morbidity and Mortality Patterns , Homa Bay regional hospital ,Kenya David Maman, Aline Niyibizi, Sept 2015
10 years of MSF intensive presence
CD4<100 cells/µL : 22.5% of all admissions.
49.6% were clinical treatment failure
Main causes of mortality :
tuberculosis
neurological infectious diseases mainly cryptococcal meningitis

9. Treatment literacy and client level self-screening

10. Late presenters screening package at PHC level ( < 200 Cd4 or stage III/IV)
Minimal package
semi quantitative CD4 LFA
CRAG test
TB LAM test
Toxo screening ( test ?)
Drug level test
+ Referral criteria
+ Intensive follow-up
TB –LAM (< 100 Cd4)
Semi –quant CD4 LFA
CRAG

11. Point of care cryptococcal antigen screening at primary care by lay counsellors in Lesotho
Outcomes
Asymptomatic and received ART + pre-emptive fluconazole at primary care by Nurse
POC CrAg LFA positive
by Lay Counsellor
CD4<100 cells/mm3
HCT+POC CD4 (PIMA)
1388
10% (136)
11% (14/129)
Yes 86% (12)
75% (9)
RIC at 5M
8% (1)
Died with TB
16% (2)
Transferred
No 14%
(2)
100% (2)
Died in hospital

12. Referral criteria and SOP’s

13. ID referral unit components

14. Minimal technical equipment - health centers <> referral level
Clinic level
Rapid tests : CRAG, malaria, HB, Hep B/C, lactate, syphilis, pregnancy
TB LAM + sputum collection ( ZN/ GenXpert )
Fine needles aspiration ( nodes)
Day monitoring
Colposcopy /pap smear
Referral level
LP + lab ( results < 6h )
Xray + ultrasounds
GenXpert
24 h Hospitalisation , vital sign monitoring , pulse oximetry, oxygen
Retinoscopy
Pleural/peritoneal tap
Experienced clinician + standard diagnostic algorithms /SOP’s

15. Conclusions
Stage III/IV presentations and mortality decreased but less than as expected ( <> Western Countries)
low CD4 presentations % still high despite high coverage figures-> naïve patients replaced by failures and drop outs
Early screening SOPs at patient/PHC/Referral levels
Need for specific interventions at all 3 levels including a referral unit with adapted technical plateau, specific training , diagnostic algorithms ,linkage with PHC level

16. Aknowledgments www.samumsf.org
Graeme Meintjes, Katherine Hilderbrand , Andrew Boulle, Meg Osler, UCT , Cape town
Maria Mashako, MSF Kinshasa
David Maman , Aline Niyibizi
MSF Field teams
SAMU team mates