1. The South African Cryptococcal Screening Program: Program update XIX international AIDS Conference Washington United States 24 th July 2012 Dr. Samuel Oladoyinbo (Treatment Lead CDC-SA) & Dr. Thapelo Maotoe (Care and Treatment Development Specialist USAID/Southern Africa)

3. Preventing deaths is a three- part strategy Lawn S. et al., AIDS 2008 Early HIV diagnosis and CD4 count Antiretroviral treatment (ART) Integrated care: prevent and treat opportunistic infections Cotrimoxazole prophylaxis TB screening Cryptococcal screening

4. Cryptococcal Screening Program: South Africa Joint collaboration with CDC/USAID Southern Africa, National Health Laboratory Service (NHLS), and the South African NDoH Phased implementation Phase 1 Reflex lab screening at all facilities using 3 pilot NHLS laboratory nodes Reflex lab screening in HIV clinics with on-site private laboratories Phase 2 Nationwide implementation using NHLS laboratory reflex screening Standard training and program monitoring tools

5. Screening for cryptococcal disease Identify patients at highest risk (CD4 <100) Test for cryptococcal antigenaemia before symptom onset Treat with oral fluconazole Prevent cryptococcal meningitis and deaths Pre-emptive fluconazole CrAg+ No symptoms Cryptococcal meningitis

6. The new dipstick test is: –Simple and quick Results in 10 minutes –Accurate Highly sensitive, accurate (>95%) –Affordable $2 per test Detects cryptococcal antigen (CrAg) in serum and cerebrospinal fluid (CSF) A new test for detecting cryptococcal disease

7. Lab-driven screening Reflex testing of remnant CD4 blood CD4 <100

9. Integration with routine HIV and TB care

10. Cryptococcal screening in South Africa Monitoring and Evaluation Training Programme Implementation Programme Coordination

11. Phase 1 implementation

12. What’s next? Phased implementation: –Phase 1 to begin training in Sept 01, 2012 –Phase 1 CD4 Labs: Helen Joseph, Tambo Memorial (E. Rand), and Pelonomi (Bloemfontein) –Nationwide stepwise: 2013 Program activities –Laboratory and clinical training –Increase awareness among health care providers and key stakeholders –Advocacy to ensure drug availability (fluconazole and amphotericin B) in South Africa –Monitoring and evaluation

13. Training Training of clinical and laboratory personnel essential Doctors, nurses, pharmacists, counselors, laboratory personnel Toolkit: –2-hour course (with training manual, PowerPoint slides, case scenarios) –Flipcharts: nurses, doctors, pharmacists, counselors –Patient educational material –Online CPD courses

14. Expected challenges Integration of HIV, TB and cryptococcal management Tracing CrAg+ patients (loss to follow-up) Up-referral of symptomatic CrAg+ patients Consent for lumbar puncture Nurse prescription of fluconazole Supply of fluconazole at primary health care level Determination of patient outcomes as part of programme monitoring and evaluation

15. PEPFAR South Africa National Department of Health of South Africa CDC- Atlanta CDC- South Africa United States Agency for International Development Southern Africa NHLS NICD Phase 1 Implementing Cryptococcal Screening Partners –FPD;WRHI, HST and RTC Acknowledgements

16. Thank You