1. Evaluating a novel semi-quantitative viral load test in the field: field trial for patient monitoring in Malawi and Uganda Dr. Suna Balkan MSF

2. Operational Need for Viral Load Measurement VL is the only reliable measure of ART efficacy Immuno/clinical signs have poor sensitivity and specificity: –False positive => Uneccessary switch to second lines –False negative => Inadequate recognition of failure Accumulation of resistances => impaired preservation of subsequent lines Added morbidity/mortality Subsequent resistance transmission in the population? In MSF (2010 data) only 1.3% of 170 000 patients active on ART were in second line due to very limited access to VL

3. Time to virological failure – MSF South Africa 0.00 0.05 0.10 0.15 0.20 061218243036 Duration on ART in months Proportion switched or with 2 VL>=5000cps/ml Kaplan-Meier failure estimate 2 Consecutive viral loads >= 5000 copies/ml Switched due to failure 1729152190851330819412311.2 (7.9-15.8) n Changed by 36 months (%, 95% CI)

4. Limited external capacity for Viral load For MSF (French section): 100 patients/mth get a VL for 40,000 patients on ART –Kenya (CDC regional lab in Kisumu & Nairobi) –Malawi (DREAM private lab in Blantyre) –Uganda (JCRC lab in Kampala) Logistical constraints (conservation of frozen plasma & transportation) Quality difficult to assess and sometimes questionable Hardly feasible to install and maintain classical molecular biology platforms in rural areas –Require staff specialised in molecular biology –Require high standard electrical supply

5. SAMBA Semi-Quantitative Test cutoff Viral load level for switching treatment varies between countries depending on resources available Current WHO recommendation for switching is 5,000 copies/ml but likely to lower cutoff Expert meeting organised by MSF recommended 400 or 1,000 copies/ml Literature shows <1,000 copies/ml do not transmit infection SAMBA semi-quantitative test is calibrated to distinguish between patients with viral loads above or below 1,000 cp/ml

6. SAMBA HIV-1 Semi-Quantitative Test PURPOSE: Viral load monitoring SAMPLE: 200 μl plasma CUT-OFF: 1,000 cp/ml HIV-1 Internal control < 1,000 cp/ml > 1,000cp/ml Test failure DIPSTICK READOUT

7. SAMBA HIV Semi-quantitative Viral Load Test Data in clinical samples from 2 London Hospitals

8. SAMBA Roche <1000>1000 <1000 95 2 136 Data from 134 HIV+ patients on ART at St Thomas & Royal London Hospitals compared to Roche TaqMan v2 Overall concordance with Roche Taqman v2 = 97.8% (131/134) SAMBA specificity (HIV neg samples) = 100 % (0/216)

9. SAMBA Field Trial Data generated at MSF site Chiradzulu district, Malawi

10. Malawi –13.2 million population 60% earn less than 1US$/day –1 million HIV-infected –68,000 AIDS-related deaths/year –225,000 patients alive on ART MSF project based in one rural district –Public health infra structures: 1 hospital, 10 health centres –Free health care (including ART) –One laboratory (hospital) MSF Chiradzulu project background

11. 2000: HIV care 2001: Free ART delivery (only at hospital) 2003: Start of decentralisation of care –≈ 70% of patients > 3h walk from hospital 2004: National programme start 2010: More than 25,000 patients alive on ART –80% of them followed in the 10 decentralised health centers –Integrated project with MoH MSF Chiradzulu project background

12. Tested on-site by SAMBA Semi-Quant Test Tested on-site by SAMBA Semi-Quant Test Roche TaqMan v2 Royal London Hospital Roche TaqMan v2 Royal London Hospital Abbott RealTime PCR Addenbrooke’s Hospital Method 200 patients recruited by MSF staff from HIV clinic during routine visit 200 µl fresh plasma Frozen plasma shipped directly Results sent to MSF Discordant SAMBA/Roche

13. Laboratory setting in the field

14. Overall concordance with Roche TaqMan v2 = 98% (196/200) SAMBA Roche <1000>1000 <1000 146 4 050 SAMBA data from 200 HIV+ patients at Chriradzulu District Hospital, Malawi compared to Roche TaqMan v2

15. SAMBA Field Trial Data generated at MSF site Arua District, Uganda

16. MSF Arua project background Northwestern Uganda Arua + catchment population: 1,5 M Adult HIV prevalence: 2.7% 3.3% HIV+ of all pregnant women tested in Arua PMTCT

17. MSF-Arua HIV/AIDS Program MSF /MoH program (AHAP) since 2000 Arua Regional Referral Hospital ARRH - 324 beds PMTCT - 2000 HAART Program - 2002 Integration of HIV/TB - 2006 Paediatric activity – 2008 Laboratory with CD4 count, haematology, biochemistry with a lot of electricity problems

18. Tested on-site by SAMBA Semi-Quant Test Tested on-site by SAMBA Semi-Quant Test Roche TaqMan v2 Royal London Hospital Roche TaqMan v2 Royal London Hospital Abbott RealTime PCR Addenbrooke’s Hospital Method 154 patients recruited by MSF staff from HIV clinic during routine visit 200 µl fresh plasma Frozen plasma shipped directly Results sent to MSF Discordant SAMBA/Roche

19. Overall concordance with Roche TaqMan v2 = 96.1% (148/154) SAMBA Roche <1000>1000 <1000 91 2 457 SAMBA data from 154 HIV+ patients at Arua District Hospital Uganda compared to Roche TaqMan v2 SAMBA specificity (HIV- samples) = 100 % (0/68)

20. Follow-up of patients All patients with VL>1000 have been traced, intensively counselled and are being re-tested 3 months later in order to confirm true treatment failure True failure (two times > 1000 cp/ml) are being prepared to switch to second line Approvals to use SAMBA in Chiradzulu & Arua projects is being requested from Ministry of Health in Malawi & Uganda

21. Distribution of viral load in ART treated and untreated patients in Arua & Chiradzulu 1,000 copies/ml 69 untreated patients 284 ART patients

22. Virological efficacy of ART over time of therapy at MSF sites in Arua and Chiradzulu > 65% of patients on ART have VL < 40 cp/ml after 6 months > 80 % of patients on ART have VL < 1,000 cp/ml after 6 months n = 284

23. Conclusion SAMBA platform is much simpler than currently available molecular technologies which require highly-trained personnel and sophisticated infrastructure only available in centralised laboratories SAMBA device is much easier to handle and being a closed system, prevents contamination by amplicons Staff training requirement for SAMBA is minimal SAMBA can be implemented in lower healthcare levels such as district hospitals or health centres with a basic laboratory but supplied with electricity Reagents do not need cold chain transport or cold storage, a considerable advantage in resource-poor settings

24. Thank you !