1. Presented to the AIDS 2016 Conference
Integrating Cryptococcal Screening into HIV care: The Namibian story Ministry of Health and Social Services Namibia Francina Tjituka: Chief Health Program Officer National HIV/AIDS, Hepatitis and STI Control Program
Presented to the AIDS 2016 Conference

2. Presentation Outline Background
Cryptococcus sero-prevalence in Namibia
Highlights of Namibia 2014 ART Guidelines
Current Cryptococcal Screening Practices
Summary
Questions and Discussion

3. Background Namibia Population 2.2m Adult HIV prevalence 14%
Slide 3
Namibia Population 2.2m
Adult HIV prevalence 14%
Estimated PLHIV
About 12% of patients initiating ART in Namibia have CD4 count < 100 cells/µL
Results of the 2014 Laboratory-based Crypto Prevalence Study among PLHIV in Namibia
CrAg prevalence 3.3% overall
3.9% for CD4+ counts of CD4+<100 cells/µL
2.3% for CD4+ counts of cells/µL

4. Source. Meditech: NIP Crypto Screening Program Data (2015)
Namibia: High-Prevalence Regions
CrAg Prevalence per Region, June 2014-May 2015
Source. Meditech: NIP Crypto Screening Program Data (2015)

5. 2014 Namibia ART Guidelines (1)
With the right amount of political will and capacity, life-saving intervention can be implemented swiftly and with marginal effort by and burden on the health system. Emphasize that the numbers

6. 2014 Namibia ART Guidelines (2)
With the right amount of political will and capacity, life-saving intervention can be implemented swiftly and with marginal effort by and burden on the health system. Emphasize that the numbers

7. Laboratory Infrastructure
40 laboratories operated by the National Institute of Pathology (NIP)
28/40 labs provide CD4 testing services.
9/28 labs use flow cytometry to conduct CD4 testing
19 have very low volume and use PIMA machines to conduct CD4 testing.
~15 labs started conducting reflexive laboratory-based screening for all samples with CD4<100 cells/µL in June 2014.
60-70% of all CD4 counts done in the country are being done in the 15 labs that are conducting CrAg screening,
We estimate that 60-70% of patients with CD4<100 cells/µL have access to CrAg screening.

8. Current Namibia Institute of Pathology (NIP) Laboratory Reflex Screening
then or +
STEP 1
STEP 2
STEP 3
Blood collected at initial patients visit
CD4 + CrAg testing on samples with CD4<100
Treatment decisions taken at first follow-up visit

9. Access to CrAg reflexive screening:
CrAg Screening in Namibia - Currently
Access to CrAg reflexive screening:
~70%
Susceptible population:
ART initiators with CD<100
ART defaulters with CD4<100
Able to access CrAg screening through clinician-initiated request for CrAg screening

10. Assessment of laboratory-based CD4 sites
Observations:
Every eligible sample received is screened for CrAg
Lab results posted to Laboratory Information System (MEDITECH) within 24 hours
Challenges:
Little control over whether results are received and used by sites
Laboratory-based

11. Assessment of sites using PIMA CD4
Observations:
Most providers aware of CrAg screening, but do not always remember to send samples for CrAg after seeing a PIMA CD4<100
Results posted within 24hrs of samples being sent for CrAg, but facility staff often do not review CrAg result until next patient visit
Equipment failure may delay results (SMS printers, MEDITECH portals)
Facilities without doctors on staff do not have access to fluconazole to begin treatment
PIMA at
Point of Care

12. Availability of fluconazole and other antifungals
Fluconazole was available in the country through the Diflucan Partnership Program until approximately 2013
Since 2013 MoHSS has been purchasing generic fluconazole
Fluconazole is part of the Namibian Essential Medicines (NEMs) list
Currently classified as an “AB” drug,
Means that it can only be prescribed by a medical officer or a specialist
Amphotericin B is available in hospitals
5-Fluorocytosine (5-FC) is not on the essential medicines list and is not available in the country.

13. Summary
Namibia has successfully integrated Creptococcal screening into HIV care
Recommendations included in the national guidelines in January 2014
The biggest NIP laboratories initiated reflexive CrAg screening on all CD4 specimens <100 cells/mm3 in June 2014.
An estimated 70% of patients with CD4<100 cells/mm3 have access to CrAg testing through the NIP Lab-based reflexive program.

14. Acknowledgements Ministry of Health and Social Services (MoHSS)
Namibia Institute of Pathology (NIP)
President’s Emergency Plan for AIDS Relief (PEPFAR).
Centers for Disease Control and Prevention (CDC)
CDC Namibia Office
CDC Atlanta: Mycotic Division

15. THANK YOU