BACK TO BASICS – AGAIN

Solange BaptisteInternational Treatment Preparedness Coalition July 19, 2015

Lessons from viral load testing in Africa

1. What’s really happening – RVL testing in 12 African countries

2. Back to Basics – Focus on treatment education and community-centered interventions

3. The Leaky Cascade – Retention and adherence concerns

4. Next Steps – What needs to happen

Overview

WHAT:– May 2015 ITPC and ARASA engaged

communities to conduct a rapid assessment of access to RVL testing

– 12 community teams gathered national level data on the current* use of RVL and implementation barriers from:• policy makers (Ministry of Health, National AIDS

Councils), • service providers (doctors, nurses, community

health workers), • recipients of treatment and care (people living

with HIV, including key populations, adolescents)• representatives of non-governmental

organizations

WHERE:– West and Central Africa: Cameroon, Cote

d’Ivoire– East Africa: Tanzania, Uganda, Kenya– North Africa: Egypt, Morocco– Southern Africa: Botswana, Malawi,

Swaziland, Zambia, Zimbabwe

State of RVL Testing in 12 African Countries

Countries surveyed (12)

GOVERNMENT POLICY WITH NO IMPLEMENTATION

– Two thirds of the 12 countries (8) surveyed, reported the existence of a government policy that mandates providers to conduct routine viral load testing as part of HIV treatment monitoring but only 3 countries were reported to have routine viral load testing

LOW HEALTH CARE PROVIDER INITIATIVE

– Almost 60% of countries were reported to have viral load tests that are patient-driven (not from health care providers)

NOT FREE – Greater than half of the countries surveyed

reported that patients accessing VL are asked to pay for the service

– Most countries reported that patients also have to pay for genotype testing if available

Key Emerging Themes

Countries surveyed (12)

Countries surveyed reporting RVL (3)

BOTSWANA

KENYA

EGYPT

UNCLEAR HOW TO GET A TEST– The steps involved in viral load testing vary widely within

and among countries and remain unclear

INCONSISTENT RESULT TURNAROUND– The time it takes to receive VLT results varies by country

ranging from 1 to 5 weeks– All countries report stock outs of test kits and/or

commodities related to VL testing within the past 12 months

– Surveys report that countries suffer from delays in results due to staff leave and stock outs

– 11 out 12 countries do not use electronic or mobile technologies to relay readiness of results to patients.

Key Emerging Themes

1. What’s really happening – VL testing in 12 African countries

2. Back to Basics – Importance of treatment education and community-centered interventions

3. The Leaky Cascade – Retention and adherence concerns

4. Next Steps – Further investments

Overview

“In Zambia, I visited an ART center in a rural area where I met 38 patients and 2 clinical officers. All the patients there that day had no idea what viral load testing was. The doctors explained that viral load testing had never really taken place since the clinic was opened in 2010 – they never received a viral load test result even if when they ordered it and the blood samples were collected. It is sad.”

Owen Mulenga – Treatment Advocacy and Literacy Campaign (TALC), Zambia

Overview

• Policies don’t improve the quality of life of people living with HIV if they are not implemented.

• VL testing is not routine. It is scarce, and expensive.

• VL load availability is only part of the equation – it must be implemented, and implemented with treatment education and adherence support:– Patients need to and have a right to understand what their viral load tests

mean – Poor support (counseling, social/community/peer) will likely have

implications for adherence

• Increased treatment coverage does not correspond to improved quality treatment.

Key Points of the Rapid Assessment

• HIV is now estimated to be the number one cause of death among adolescents (10-19) in Africa. • Perinatally infected adolescents are

most in need of robust VL monitoring to determine if, and to switch to better regimens

- 2015 Adolescent Treatment Coalition (ATC)

Investing in Our Future – Safeguarding Adolescents

1. What’s really happening – VL testing in 12 African countries

2. Back to Basics – Importance of treatment education and community-centered interventions

3. The Leaky Cascade – Retention and adherence concerns

4. Next Steps – Further investments

Overview

Abbreviated HIV treatment cascade for sub-Saharan Africa, 2012

Sources: 1. UNAIDS 2012 estimates; 2. Demographic and Health Surveys, 2007–2011 (www.measuredhs.com); 3. Kranzer, K., van Schaik, N., et al. (2011), PLoS ONE; 4. GARPR 2012; 5. Barth R E, van der Loeff MR, et al. (2010), Lancet Infect Disease.

Notes: No systematic data are available for the proportion of people living with HIV who are linked to care, although this is a vital step to ensuring viral suppression in the community.

TESTING

LINKAGE

RETENTION

1. What’s really happening – VL testing in 12 African countries

2. Back to Basics – Importance of treatment education and community-centered interventions

3. The Leaky Cascade – Retention and adherence concerns

4. Next Steps – Further investments

Overview

Supporting community-led, tailored, country level research to investigate the multi-factoral reasons why the system is not working well for PLHIV.

Supporting community-led advocacy to remove barriers that prevent access to RVL.

Get serious about treatment education. Fund it! Education efforts focus on the importance of routine viral load testing for people living with HIV, and health care providers, including community actors (peer counselors).

Advocating for the strategic rollout/scale-up of RVL, not a targeted rollout.

What now?