Implementation of routine HIV viral load monitoring A multisite cascade analysis Munyaradzi Dhodho1, Marthe Frieden1, Amir Shroufi2, Esther Wanjiru3, Sarah Daho3, Erica Simons4, *Helen Bygrave5 1Médecins Sans Frontières (MSF), Harare, Zimbabwe; 2MSF, Cape Town, South Africa; 3MSF, Blantyre, Malawi; 4MSF, Maputo, Mozambique; 5MSF Southern Africa Medical Unit, Cape Town, South Africa

90% Have a suppressed viral load Reaching The Third 90 90% Know their HIV status 90% Are retained on ART 90% Have a suppressed viral load

Reaching The Third 90 Globally Less than 30% of patients have access to viral load (VL) testing National VL Coverage Malawi 17% Zimbabwe 5% 90% Know their HIV status 90% Are retained on ART 90% Have a suppressed viral load

Background From 2012, routine VL testing was introduced in 6 MSF projects in Lesotho, Malawi (2), Mozambique, and Zimbabwe (2). All districts were rural settings where ART had been extensively decentralised to primary care clinics (10-30 clinics/district ) Malawi Thyolo and Nsanje Mozambique Changara Zimbabwe Buhera and Gutu Lesotho Roma

Background All sites scaled up VL testing using Dried Blood Spot samples ( DBS) Using a centralised high throughput VL platform (bioMérieux NucliSENS) All sites performed annual viral load except Malawi (every 2 years )

Objective: To Assess The Viral Load Cascade in each site Step 1: Coverage of Viral Load Testing

Objective: To Assess The Viral Load Cascade at each site Step 1: Coverage of Viral Load Testing Differentiate ART delivery ( Clubs, CAGs, fast track) Step 2: Acting on the result (< or > 1000 copies/ml) Counselling and Repeat VL

Objective: To Assess The Viral Load Cascade at each site Step 1: Coverage of Viral Load Testing Differentiate ART delivery ( Clubs, CAGs, fast track) Step 2: Acting on the result (< or > 1000 copies/ml) Counselling and Repeat VL Switch to Second Line Remain on 1st Line

Methods Analyses performed between Jan and Nov 2015 Reviews of clinical and laboratory records 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

Results: Coverage ( n=24,263) Site Buhera, Zimbabwe Gutu, Zimbabwe Thyolo, Malawi Nsanje, Malawi Roma, Lesotho Changara, Mozambique Total Year routine VL testing started 2012 2013 2014 Number of patients in the analysis 4760 2978 7576 2785 3069 3095 24263 Coverage of routine VL testing (VL1) 91% 74% 56% 32% 70% 62% 65% Routine VL Coverage 32-91%

% > 1000 copies/ml 9-40% Results Site Buhera, Zimbabwe Gutu, Zimbabwe Thyolo, Malawi Nsanje, Malawi Roma, Lesotho Changara, Mozambique Year routine VL testing started 2012 2013 2014 Number of patients in the analysis 4760 2978 7576 2785 3069 3095 Coverage of routine VL testing (VL1) 91% 74% 56% 32% 70% 62% VL > 1000 copies/ml 14% 15% 9% 20% 10% 40% % > 1000 copies/ml 9-40%

Results: Coverage Success Challenge Task-shifting of sample preparation to lay workers Use of electronic medical records (EMRs) to flag patients due for VL Demand creation with patients Poor patient triage and patient flow Prolonged turn-around time from laboratory  demotivation

Results: Action on High Viral Load

Results: Switch To Second Line Overall switch rates were low Between 10 and 38% BUT Considerable scale up compared with targeted VL > 6x as many 2nd line initiations in Buhera from 2012-2013

Results: Action on High Viral Load Success Barrier Dedicated VL focal person to identify and follow-up patients Flagging of results Use of EAC register and High Viral Load (HVL) form Monthly lists identifying patients with a HVL for supervision team to use Poor patient triage No dedicated staff member to perform enhanced adherence counselling (EAC) Lack of supervision and follow up Lack of task-shifting and decentralisation of second- line ART initiation

Cost of No Action Financial cost of taking a VL test and not acting e.g in Changara $8865 spent on VL tests with result > 1000 copies/ml but no action taken Patient cost – timely switch to second line Public health cost – ongoing HIV transmission

Conclusion Scaling up VL is feasible in resource poor settings Analysing the VL cascade at site level is essential to ensure tests are taken and results utilised Equal investment must be made into programmatic implementation of VL, as in establishing VL testing capacity There is an urgent need to task shift and decentralise second-line ART initiation and follow-up

Acknowledgements Ministries of Health, MSF field teams and the patients in Lesotho, Malawi, Mozambique and Zimbabwe UNITAID