1. Durban, July 20th 2016 Ruggero Giuliani MSF - Mozambique
Viral load cascade and programmatic challenges after 2 years of routine HIV viral load testing in Maputo, Mozambique
Durban, July 20th 2016
Ruggero Giuliani
MSF - Mozambique

2. Summary
Background
Objectives
Methods
Results
Programmatic challenges

3. Background
From 2013, routine VL testing was introduced in 7 MSF supported HC in Maputo city, Mozambique
All districts were urban settings where ART had been extensively decentralised to primary care clinics
All sites scaled up VL testing using
Dried Blood Spot samples ( DBS) on Venous Blood
Centralised VL platform (bioMérieux NucliSENS)
Pilot Routine Viral Load in all sites ( 1 VL every 12 Months ) able VL >=

4. Objectives Coverage evolution of VL testing in time
VL detectability >= 1,000 cp/ml
Counselling and repeat VL
Ressupression to <1,000 cp/ml and switch to 2 line

5. Methods Analyses performed between 2013 Q4 and 2015 Q4
Source of data to determine how each step of the VL cascade was implemented within a defined period according to local guidelines
Results were presented to programme staff and barriers for implementation identified ( task force at Health Facility level)

6. Results
Total eligible*
24,447
VL1 Ø
11,605 (47%)
VL1
12,842 (53%)
≥ 1000
2,561 (21%)
< indetc
10,281 (79%)
Figure 1. VL cascade, 1rt VL completion and detectability. Maputo, 2013 to 2015.
*>= 6 months on ART
Time on ART n
freq.
<12m
1,413
10%
12 |-- 24m
2,348
17%
24 |-- 36m
2,170
15%
>=36m
8,112
58%
Total
14,043
100
Initial Priority on Patient longer on treatment – Higher probability of failure
Source: Tier.Net/MSF

7. Coverage increased gradually!
Results
Coverage increased gradually!
Add scale up of VL by quarter – graph
Graph 1. First VL coverage by quarter. Maputo, 2013 to 2015
Source: Tier.Net/MSF

8. INCREASE VIRAL LOAD COVERAGE
CHALLENGES STRATEGY ADOPTED
Difficult mind shift among Clinicians (from CD4 to VL )
Lack of flow and task
Poor Laboratory capacity for blood collection
Poor knowledge among Patients and Health Care workers
Initially VL request combined with every CD4 request
Creation of Task Force at Facility Level / Viral Load Officer!
VL collection station (in high volume facilities)
Periodical Viral Load Campaigns inside the facilities + National campaign with Radio/TV msgs
Add scale up of VL by quarter – graph

9. Results
Figure 2. VL cascade, EAC, 2ed VL completion and ressupression. Maputo, 2013 to 2015.
≥ 1,000 cp/ml
3,762
EAC Ø
2,113 (60%)
EAC
1,397 (40%)
CV2 >3M
1,261 (37%)
≥ 1000
810 (64%)
< indetc
451 (36%)
CV2 Ø
2501(63%)
*Active >=3m after VL1, n=3,510
Losses=252
*Active >=6m after VL1, n=3,397. Losses=365.
**Opportunity based on sample collection dates
Source: Tier.Net/MSF

10. Opportunity of 2nd Viral LOAD
Repeat VL
Not done
Done < 3m
Done 3 to 9 m
Done > 9 m
Total
Maputo
2561
125
(9%)
614
(44%)
647
(47%)
1,386
(100%)
Table 1. Second VL completion. Maputo, 2013 to 2015.
Source: Tier.Net/MSF

11. INCREASE ADHERENCE COUNSELLING and 2nd VIRAL LOAD COVERAGE
CHALLENGES STRATEGY ADOPTED
Increase number of counselors and training on Enhanced adherence intervention (EAC)
Presence of a Counselor in the Pharmacy
Use of electronic medical records (EMRs) at Consultation
Use of electronic Dispensing Tool (Idart ) at Pharmacy Level
Availability of Counselors
Identification of Patients in need of Adherence intervention
Identification of Patients eligible for 2nd VL
Add scale up of VL by quarter – graph

12. Access to Second Line Treatment
Figure 4. Second line cascade. Maputo, 2013 to 2015.
2 HVL
(≥1,000 cp/ml)
n= 1044
Referred to CTARV
n= 678 (65%)
Approved by CTARV
n= 627 (92%)
2ed line switch
n= 455 (72%)
*Aggregate data
**Data collection challenging: patient transfer for 2ed line and multiple source of data
Source: Tier.Net and second line register/MSF

13. Referral to ART committee Approval by ART committee
Results
Table 2. Opportunity of cascade steps. Maputo, 2013 to 2015.
All HC
Median (IQ range)
days
Referral to ART committee
129 (188)
Approval by ART committee
5 (7)
2ed line switch
22 (33)
Overall
153 (192)
*Excluded missing data in variables of interest. N of observ.: 208 to 579
Data collection challenging: patient transfer for 2nd line and multiple source of data
Turn around time of reception and result in the Lab increased from 0 to 41 days in the period
Referral letter to ART committee centralized in the HC director
Source: Tier.Net and second line register/MSF

14. ACCESS TO SECOND LINE TREATMENT
CHALLENGES STRATEGY ADOPTED
ART Committe at Facility Level
E-Submission / provision of Computer in Facilities
2nd Line counselling initiated at PHC level
Counselor Follow-up at Hospital level
Progressive decentralization of 2nd line management ( National –Provincial-District- Health Facilities)
Identification of Failures
Submission to National Committee TARV
Transfer of Patients to referral Centers ( Hospital )
Add scale up of VL by quarter – graph

15. CONCLUSIONS
Implementation of Routine VL require a multidisciplinary approach and a well established flow
Creating demand for viral load testing require continuous sensitization of patients and Health Care workers education
Increase of VL Demand need adaptations of Laboratory capacity (equipments, reagents,H.R. , etc)
Lay Counselors are essential to ensure adherence intervention
Decentralisation and task shifting of second line ART initiation and follow up, with continuous access to second line drugs is a key enabler in the cascade.

16. Durban, July 20th 2016 Ruggero Giuliani MSF - Mozambique
Thank you!
Durban, July 20th 2016
Ruggero Giuliani
MSF - Mozambique