1. Scaling Up Retinal Screening in an HIV clinic in Nanning, China to prevent blindness from CMV retinitis Peter Saranchuk, MD TB-HIV Adviser Southern Africa Medical Unit (SAMU) Operational Centre Brussels (OCB) Médecins Sans Frontières (MSF) Advances and Opportunities to Address CMV retinitis Satellite Symposium IAS Conference 30 June 2013

3. HIV late presenters 31.8% Of people present for the first time with a CD4 count < 200 cells/µL

4. CMV: The 3rd most common/serious OI

5. Prior to Nov 2008 in Nanning Problem: Diagnosis of CMV usually delayed –Retinal screening not done –Diagnosis made only after vision loss had already occurred –Irreversible –Required referral to a secondary hospital

6. Poor Outcomes (prior to Nov 2008) Of 17 patients assessed in Nov 2008 and found to have active or inactive CMV retinitis: –5 (29%) had bilateral involvement –7/11 eyes (64%) with inactive disease were blind* * <20/400 visual acuity and/or able to count fingers at 10 feet

7. Solution

8. Training in retinal examination Over 4 days By an ophthalmologist (D. Heiden) Of HIV clinicians In the use of an indirect ophthalmoscope (IO) E-mail address given for follow-up support

10. Ophthalmoscopy The key to both = use dilating drops Indirect Direct Vs.

11. After Nov 2008 in Nanning Retinal screening –Performed routinely –In all at-risk patients (e.g. those with CD4<100) –By HIV clinicians –Using an indirect ophthalmoscope –In the HIV clinic

12. CMV retinitis has a typical pattern

13. After Nov 2008 Now able to diagnose CMV retinitis: –At the first visit –Within minutes –Inexpensively –At primary HIV care level –More easily than other common, serious OIs!

14. After Nov 2008 Now able to diagnose CMV retinitis: –At the first visit –Within minutes –Inexpensively –At primary HIV care level –More easily than other common, serious OIs! = A point-of-care diagnostic!

15. Every HIV clinic should have… A bottle of drops to dilate pupils E.g. Tropicamide

16. Ophthalmologists still involved Telemedicine –E-mailing of digital retinal images Complicated cases –Immune Recovery Uveitis (I.e. IRIS) –Retinal detachment

17. After Nov 2008 Routine retinal screening  Earlier diagnosis  Earlier treatment  Improved visual outcomes –E.g. Minority of patients now being diagnosed with CMV retinitis are blind

18. Subsequent Trainings

19. Average duration of treatment in Nanning ~4.5 months N.B.: ART needs to be initiated as soon as possible

20. Usual Treatment: Sticking needles into eyes!

21. Price of valganciclovir needs to be… <1 dollar per tablet to prevent CMV-related blindness and encourage retinal screening

22. Conclusions 1.Retinal screening performed routinely prevents CMV-related blindness 2.Can be done by trained HIV clinicians –In resource-limited settings 3.Diagnosis of CMV retinitis then becomes easier than other OIs! 4.Need a treatment which is both convenient and affordable

23. Acknowledgments Dr. David Heiden Pacific Vision Foundation Seva Foundation Chinese partners –Guangxi CDC –The Fourth Hospital of Nanning

24. Treatment options in Nanning Intravitreal injections (weekly) –Inexpensive –Barbaric! I.v. ganciclovir (daily) –Expensive –Inpatient vs. outpatient? Oral valganciclovir (VG) –Convenient –Outrageously expensive (~40 USD per tablet)