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

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

CMV: The 3rd most common/serious OI

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

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

Solution

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

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

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

CMV retinitis has a typical pattern

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!

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!

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

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

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

Subsequent Trainings

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

Usual Treatment: Sticking needles into eyes!

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

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

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

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)