1. 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

2. 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

3. 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

4. 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

5. 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 )

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

7. 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

8. 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

9. 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

10. 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%

11. % > 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%

12. 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

13. Results: Action on High Viral Load

14. 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

15. 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

16. 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

17. 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

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