Viral Load in Zimbabwe: Results Transmission and Clinical

Management

Shirish Balachandra, CDC Zimbabwe Claudios Muserere, ITECH Zimbabwe

October 2017

Background Context

HIV Epidemic

• ~1,330,500 PLHIV

• ~1,103,000 on ART • 83% ART coverage • Note: this reflects a combination of

program and survey data

• ~86% virally suppressed (age 15-64), per ZIMPHIA

• Note: ZIMPHIA ART coverage was only ~64% among age 15-64, translating to 55% community suppression

Viral Load Scale-up

• By end 2015, national VL coverage was only ~3%

• 20% by end 2016 • 40% by end 2017

• PEPFAR and GF combined support • Equipment (Roche/Abbott/BM),

reagents, HRH, mentorship

Zimbabwe ART Monitoring: Viral Load

• Viral load is recommended as the preferred approach to diagnose and confirm treatment failure

• Viral load failure is defined as persistent viral load >1000 copies

• Viral load should be measured at 6M, 12M then every 12M

• Dried blood spots can be used to determine viral load

Viral Load Testing in Zimbabwe (October 2016 - June 2017)

Total Number of Viral Load Tests 353,730 Tests

PEPFAR sites Non-PEPFAR sites

88,308 tests (25%) Non-PEPFAR Sites

265,422 tests (75%) PEPFAR Sites

Zimbabwe is currently implementing the BIKA

Laboratory Management

Information System (LIMS) at 6 Provincial

laboratories.

Interventions planned: Electronic results transmission to

facilities and SMS action notifications to patients

Integration of EHR and LIMS for electronic referrals from facility to laboratories and results back

to facility.

Image source: www.bikalabs.org

BIKA LIMS in use at the viral load testing laboratories to improve turn around time for laboratory testing

Critical value results (patients with high viral load) are identified and shared via phone/email with facilities

Total suppression amongst patients tested was 83% (Oct 2016 – May 2017)

67%

81% 86%

0%

50%

100%

<15 years Men 15+years

Women 15+years

Not suppressed (≥1000 copies/ml)

Virally suppressed (<1000 copies/ml)

More adult women were

virally suppressed than men and under

15 year olds.

Nkunzi Clinic: Tsholotsho District

1012

860

700

78

78

40

40

1

96

0 200 400 600 800 1000 1200

Total ART CohortTotal V/load done

Total results receivedHigh V/load

Attending EACCompleted EAC

Repeated V/loadsDeaths during EAC

Awaiting results

Number of clients

Paediatric Cohort Prioritization: Nkunzi Clinic

46

42

42

17

17

8

8

0

5

0 5 10 15 20 25 30 35 40 45 50

Total ART Cohort

Total V/load done

Total results received

High V/load

Attending EAC

Completed EAC

Repeated V/loads

Deaths during EAC

Awaiting results

Number of clients

Actions for VL Results

• Suppressed VL • Patient continues first line, referred for community ART

monitoring and is eligible for differentiated care models • Unsuppressed VL

• Patient referred for second line (mentors and DR’s) and continued adherence support

Clinical Management of High VL Results • Pregnant women, adolescents, and children prioritized • Clients with high VL are prioritized for reduction in TAT (electronic

results transfer to facilities) • Clients called back to facility (if their booked date is >one week from

date of receiving results) and recorded in EAC register to track EAC sessions

• Opportunistic infection screen • Three EAC sessions with monthly drug supply and close monitoring • V/load repeated after 3 months of good adherence

EAC Register Format

Enhanced Adherence Counselling Register

Patient name

OI number

Date results received

Viral load result

Date first EAC

Date second EAC session (one

month after 1st EAC

Date second EAC session (one month

after 2nd EAC)

Date repeat V/load (one

month after 3rd EAC)

Repeat VL result

Action taken - continue of

1st line / switch to 2nd

line

Adapted from latest version of the OSDM

Conclusions and Lessons Learned • Routine viral load monitoring can be implemented successfully at facility

level • Long TAT can delay appropriate care to clients, more importantly for

unsuppressed clients • Innovations to speed up transmission of results can go a long way in improving

patient management

• Uptake of viral load among PLHIV is very high and can motivate clients to be more adherent

• Capacity building for health workers is important for better results and client management