1. Amir Shroufi Medical Coordinator MSF South Africa
Community, Primary healthcare & hospital responses to advanced HIV & Models of care
Amir Shroufi
Medical Coordinator
MSF South Africa

2. All deaths in South Africa - 2015
Around 150,000 deaths in 2015.

3. All deaths in South Africa, 15- 49 - 2015
This meta-analysis shows that CD4 counts at presentation to care and at ART initiation in sub-Saharan Africa have not increased over the past decade. Patients with CD4 <200 cells/uL are at higher risk of dying.

4. In eshowe, 10% TB, 7% HIV, 3 intestinal, 2.8 influenza & pneumonia

5. ART Initiations, Eshowe KZN 2010-2015
This meta-analysis shows that CD4 counts at presentation to care and at ART initiation in sub-Saharan Africa have not increased over the past decade. Patients with CD4 <200 cells/uL are at higher risk of dying.

6. ART status of PLHIV with CD4 < 200 CD4 Epicentre/MSF CHAPS surveys Kenya, Malawi, & South Africa
Courtesy of Menard Chihana & David Maman, Epicentre/UCT, Cape town

7. Men present later, higher mortality
2013, Eshowe: 1,077 HIV +ve never tested, 2/3 male
This meta-analysis shows that CD4 counts at presentation to care and at ART initiation in sub-Saharan Africa have not increased over the past decade. Patients with CD4 <200 cells/uL are at higher risk of dying.
2015, SA – 76,000 male HIV deaths, 79,000 female

8. Missed opportunities In 4/9 clinics GxP routinely used
IPT use: 37% of eligible
Switch to 2nd line too late
Fluconazole not given 50%
Nurses prescribe fluconazole
5/9 clinics
Defaulters not systematically traced
How do we address this, and do so in settings where most clinics will not have any doctor
File review of 9 MSF supported PHC clinics, Eshowe, KZN, SA 2016.

9. Lesotho: PHC CrAg screening
From community, may 2014-june 2015
Facility based
HTC
Adherence support , Link to support groups, Assist in clinical tasks , Defaulter tracing, Record keeping

10. KZN: more comprehensive strategy all presenting with CD4 < 200
LAM
X-pert
CrAg LFA
IPT-CTX-B6
Same day ART
Follow up
This meta-analysis shows that CD4 counts at presentation to care and at ART initiation in sub-Saharan Africa have not increased over the past decade. Patients with CD4 <200 cells/uL are at higher risk of dying.
Mention that LP for CrAg positives is a bit of a grey area, patients tend to refuse.

11. KZN: Enhanced TB screening
Blanket screen for all CD<200
Aims to increase detection
This meta-analysis shows that CD4 counts at presentation to care and at ART initiation in sub-Saharan Africa have not increased over the past decade. Patients with CD4 <200 cells/uL are at higher risk of dying.

12. Khayelitsha: Dis & re engagement with care
One quarter (25.1%) of patients disengaged from ART care at least once from
After disengagement, 1,459 patients (16.2%) were hospitalized and 237 (2.6%) died.
Khayelitsha township, Cape Town, South Africa (population ~500,000). Ore than 50,000 on ART since Data was used from all 13 public sector clinics. 65% retention at 6 years. Disengagement = not seen 180 days.
Analysis Jan 2013 – Dec people who disengage at increased risk morbidity & mortality & to transmit to others.
Deaths ascertained 6 month after the end of the period of interest.
Contemporary disengagement from antiretroviral therapy in Khayelitsha, South Africa, Samantha Kaplan1 et al, poster # 162, CROI 2017

13. Failure to switch: need new algorithms
Outcome
BUHERA
GUTU
CHIKOMBA
VL Coverage
80%
83%
74%
VL detectability
12%
13%
15%
EAC documented
63%
81%
78%
Repeat VL test
77%
72%
66%
Re-suppressed to <1000copies/ml
45%
47%
25%
% eligible switched to 2nd line
39%
14%

14. Malawi: Support to Nsanje hospital
MSF has been supporting the HIV programme of the MoH in Nsanje district since 2011 through mentorship
In 2016 a population based survey demonstrated
77% of people living with HIV know their status,
90% of people who know their status are on ART
91% of those on ART are virologically suppressed
In 2016, MSF decided to scale up support to Nsanje District hospital
This meta-analysis shows that CD4 counts at presentation to care and at ART initiation in sub-Saharan Africa have not increased over the past decade. Patients with CD4 <200 cells/uL are at higher risk of dying.

15. Nsanje: causes of admission vs death
Admissions, May – December 2016
Deaths, May – December 2016
29% within first 48 hrs
HIV
HIV
Admission data based on a total of 1183 admissions. The cause of death, n=165. TB
HIV / TBV
HIV / TBV

16. Advanced Disease - 2 Kinshasa Hospitals
Variables
CHK, N=1285
n (%)
HGR RB, N=495
Age (yrs)
39 [32- 46]
39 [32- 47]
Median CD4
76 [24-77]
68 [ ]
ART experience
994 (77.4%)
252 (50.9%)
Mortality
291 (22.6)
124 (25.1)
Duration stay
(days)
4 [2- 8]
4 [2- 9]
This is all HIV positive hospital admissions in 2 MSF supported hospitals in Kinshasa. Most are ART experienced as opposed to ART naive. Very high mortality.

17. Summary Care packages important – nurse driven systems
Screening vs presumptive treatment
Increasing importance retention & suppression
Lower thresholds
To switch – new algorithms needed
To treat
This meta-analysis shows that CD4 counts at presentation to care and at ART initiation in sub-Saharan Africa have not increased over the past decade. Patients with CD4 <200 cells/uL are at higher risk of dying.