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The role of virological monitoring A clinical perspective Eric Goemaere MSF South Africa.

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Presentation on theme: "The role of virological monitoring A clinical perspective Eric Goemaere MSF South Africa."— Presentation transcript:

1 The role of virological monitoring A clinical perspective Eric Goemaere MSF South Africa

2 Treatment simplification? HIV/TB integration PHC decentralization Task shifting Simplified treatment

3 Impact of routine monitoring <> Immuno- clinical monitoring on regimen change Project/ Country nMedian time on ART on second line Thyolo, Malawi M0.4 % Buhera, Zimbabwe M1.6 %

4 VL monitoring in LIC : a love/hate story HIV Viral Load Monitoring in Resource-Limited Regions: Optional or Necessary? Alexandra Calmy,1,5 Nathan Ford,6 Bernard Hirschel,2 Steven J. Reynolds,7 Lut Lynen,4 Eric Goemaere,8 Felipe Garcia de la Vega,1Luc Perrin,3 and William Rodriguez9,10, CID 2007:44 HIV Viral Load Monitoring in Resource-Limited Regions: Optional or Necessary? Alexandra Calmy,1,5 Nathan Ford,6 Bernard Hirschel,2 Steven J. Reynolds,7 Lut Lynen,4 Eric Goemaere,8 Felipe Garcia de la Vega,1Luc Perrin,3 and William Rodriguez9,10, CID 2007:44 More accurate assessment of treatment failure will reduce the delay in switching to second-line drugs. Targeted use of VL can limit unnecessary switching and routine use of VL can reduce the risk of resistance. WHO 2010 guidelines Keiser et al, AIDS 2011

5 Female, CHK Kinsahsa N° , DOB 11/10/1972 Exclusive Immuno/clinical monitoring delays clinical reaction Phase IV Oesophageal candidiasis VL VL > moved to 2 nd line Cd4 < 30 % Cd4 < 50 %

6 Predicting virological failure ( < 30 % of nadir CD4) in adults M. Pujades, L. Pinoges, Epicentre, not published Sensitivity = 17.2% (12.3% %) Specificity = 94.5% (93.6% %) Sensitivity = 17.2% (12.3% %) Specificity = 94.5% (93.6% %) PPV = 18.5% (13.3% %) NPV = 94.0% (93.1% %) PPV = 18.5% (13.3% %) NPV = 94.0% (93.1% %)

7 Predicting virological failure in children – Thailand: US IF criteria to identify children with single viral load >1000 copies/ml after 1 year of treatment (n=202) Sensitivity: 15%; PPV: 16% (Jittamala et al. 2009) – Uganda: WHO IF criteria to identify children with confirmed viral load >400 copies/ml for (n=116) Sensitivity: 0% (Ruel et al. 2010) – South Africa : criteria to identify children with VL > 1000 cp/ml ( n = 2543 ) Sensitivity 5 %, PPV= 42 % ( Mary Ann Davies, Durban Aids conference June 2011) – Thailand: US IF criteria to identify children with single viral load >1000 copies/ml after 1 year of treatment (n=202) Sensitivity: 15%; PPV: 16% (Jittamala et al. 2009) – Uganda: WHO IF criteria to identify children with confirmed viral load >400 copies/ml for (n=116) Sensitivity: 0% (Ruel et al. 2010) – South Africa : criteria to identify children with VL > 1000 cp/ml ( n = 2543 ) Sensitivity 5 %, PPV= 42 % ( Mary Ann Davies, Durban Aids conference June 2011)

8 Impact in early detection of VF Viral load at 3 months after initiation of antiretroviral therapy is associated with better virological and treatment outcomes than at 6 months. B. Kerschberger 1, A. M. Boulle 2, K. Kranzer 3, K. Hilderbrand 1,2, M. Schomaker 2, D.Coetzee 2, E.Goemaere 4, N. Ford 2,5, G. Van Cutsem 1,2 VL3 group : 22% less likely to experience subsequent virological failure, 27% less likely to be later switched to second line regimen

9 If no access to VL, priorities for VL ? Steven Van Den Broucke, Sandra Simons, Katharina Kranzer Dhodho Munyaradzi, Carol Metcalf, Kwenzakwenkosi Ncube, Helen Bygrave Poster : THPE725 Thursday 26th

10 Impact of late viraemia detection on horizontal and vertical transmission ? Horizontal transmission Vertical transmission – PMTCT B + : danger for subsequent pregnancies Horizontal transmission Vertical transmission – PMTCT B + : danger for subsequent pregnancies p2p3p4 HIV (+): ART: LTF: 12 M** Pre-ART Facility based HCT : Enrolled in care: LTF: 6 M Out of facility HCT : LTF:

11 Impact of late viraemia detection on resistance building ( TAM and K65R) Source : The public health approach to identify antiretroviral therapy failure: high-level nucleoside reverse transcriptase inhibitor resistance among Malawians failing first-line antiretroviral, Therapy, Mina C. Hosseinipour & all, AIDS 23:1127–1134

12 Conclusions Immuno/clinical monitoring do not replace virological monitoring Key challenges are around technical/ geographical / financial access to virological monitoring Unitaid/ Chai/Unicef / MSF concerted efforts will work on all 3 aspects to make virological monitoring a reality in LIC by 2015

13 Acknowledgements MSF & MOH teams in Zimbabwe, RDC and South Africa Helen Bygrave, Teri Roberts,Nathan Ford All the ones fighting to be ‘ viral load undetectable’

14 Thank You


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