IAS Education Programme at ICASA 2008 Lessons from Practice Paula Munderi

IAS Education Programmeat ICASA 2008

Lessons from Practice

Paula Munderi

Background – what you have told us

Clinical Care Workers

ART clinics – mainly public sector (NGO)

Large Clinics (hundreds of patients) More women than men

Some children

National ART Guidelines – basis WHO PH approach

Where do your patients come from ?

Clinical services (through PITC)

VCT services

CBOs of PWA

Other programs PMTCT programNutrition rehabilitation centers - paediatrics

Initiation of ART – how do you assess your patients?

Clinical Staging

CD4 guided staging (<200 / <350) VL – limited to research facilities

Baseline clinical tests FBC, Liver function, Renal Function, Pregnancy Test, CXR

? Access to lab tests limited

? Lipids / Glucose – in the long term for PIs

ART preparedness & Counseling emphasized

The Selection of ARVs you use

1st Line 2NRTI + NNRTI

Stavudine / Zidovudine / Lamivudine

N[d4T/AZT/3TC + NVP/EFV]

2nd Line 2NRTI + bPI [Abacavir/ Tenofovir/ ddI + rLPV / NFV]

Limited formulary – Focused procurement & Training

? The role of new ARVs

How you follow up your patients

Disease progression Clinical assessment

CD4

VL ?

Side Effects FBC, Liver and Renal function, Lactate

Adherence Appointment keeping

Patient self report

Pill counts

Monthly to 3 monthly visits

‘Fast Track Nurses’ for stable patients

Some of the challenges you have in common ….

Human Resources Maintaining adherence – stigma, distance, SE’s Family treatment – children Access to medicines & Access to monitoring tests Specialist support and referral for complex cases Maintaining risk reduction and prevention

Alchohol and substance abuse Alternative medicine: traditional / religious

Family planning

Case Study: Stigma as a barrier to Adherence. Jean Claude , Rwanda

Widespread stigma and fear of disclosure Patients don’t seek care appropriately

Education, assisted disclosure, treatment companion and a multi disciplinary team approach

? Can we mix all consultation services so HIV +ve patients don’t feel isolated ?

Case Studies: Barriers to Adherence - Distance, Lack of Psychosocial support, Civil Unrest

Joseph Gasper, Tanzania. Philip Owiti, Kenya

I - Hard to reach populations

II - So much for ‘pill counts’ !!!

III – Civil unrest : Planning for it ?

Case Study: Side Effects of ARVs as a barrier to Adherence. Yeshiwork Mekuria Tefera, Ethiopia

‘Physical’ side effects of ARVs.

? What are some of these side effects?

How these can be a barrier to adherence

Strategies to handle these

Treatment of children

Paediatric Case Presentation

BOGNON TANGUY, Benin

Case Study: Treatment of ChildrenOlawale Fadare, Nigeria

AM, 4yrs old girl; Mother HIV +ve and on ART Father refused to test

No staging indicators; CD4 567 (21.5%)

ART deferred ; CTX prophylaxis; advised 6 mnth R/V Started ART with Combivir BD from an alternative

‘private’ facility

Action: Withdrawal of ART; Counseling and Education

? Was action appropriate …..

Case Study: Switching to 2nd lineSunday Fagbnero , Nigeria

The Challenge: Viral load not available to all clients ?Early identification of need to switch to 2nd line ARVs

Action: A Viral Load Algorithm was developed to select patients

likely to have failed the 1st line medication. Clinicians were trained to implement the algorithm and

select clients for viral load Those with elevated viral load are the switched to second

line medication.

Case Study: Switching to 2nd lineSunday Fagbnero , Nigeria

Impact of solution:

Led to early identification of clients failing on 1st line

ARVs and prompt switching to 2nd line ARVs

Lessons learnt:

Limited resources can be better managed by focusing the

main segment of the clients with specific need instead of

deploying resources to all clients in the ARV service.

? In view of the large number of HIV positive clients and those requiring

switching to second -line medication in ARV services ,would it be feasible

to provide regular viral load monitoring for all clients in care?

Case Study: Maintaining risk reduction and

prevention . Sunday Fagbnero , Nigeria

Challenges:

Patients continue engaging in high risk behaviour while on

ARVs. Risk of:

re-infection development of resistant HIV strains reduced uptake of ARVs among positive clients due to

perception of ineffectiveness from observing poor response of clients on medication

Case Study: Maintaining risk reduction and

prevention . Sunday Fagbnero , Nigeria

Actions Identification and training of Peer-Peer Educators Trained on Basic of HIV Adherence and positive

prevention activities

Impact of action: Improved uptake of positive prevention activities among

clients Reinforcement of positive prevention practices among

clients selected

Lesson Learnt: HIV positive clients have great potential in contributing to

improved health status of other clients.

? Expert Patients

Further Questions:

Are there other ways motivated PLWHAs can be utilised in improving the health status of other HIV positive clients?

Case study: Responding to patients’ socioeconomic challenges. Jules BB, Benin

The unseen costs to patients of following ART• Increased medical consultations

• Hospitalisation

• Diagnostic investigations

• Transport to clinics

• Food

Socio – economic constraints that make treatment

difficult and how one clinic has handled these.

Case Studies: The challenge of family planning

and Desired Conception

I Joseph Gasper, Tanzania

II Ghada Shaka, Namibia

Virologic ClinicalImmunologic

Viral load CD4 countClinicalcriteria

"Early Switch" "Late Switch"

Failure / When to Switch

Clinical, CD4 Cell Count, and Virological Definitions of Treatment Failure

for Patients on a First-Line Antiretroviral Regimen

Clinical failure a Occurrence of new or recurrent WHO stage 4 condition b c

CD4 cell failure d Fall of CD4 count to pre-therapy baseline (or below) or

50% fall from the on-treatment peak value (if known) or

Persistent CD4 levels < 100 cells/mm3 e

Virological failure Plasma viral load >10,000 copies/ml f

a. This event must be differentiated from the immune reconstitution inflammatory syndrome (IRIS)

b. Certain WHO clinical Stage 3 conditions (e.g. pulmonary TB, severe bacterial infections), may not be an indication of treatment failure, and thus

not require consideration of second-line therapy;

c. Some stage 4 conditions ( EPTB: simple lymph node TB, uncomplicated TB pleural disease, esophageal candidiasis, recurrent bacterial

pneumonia) may not be an indicator of treatment failure and thus not require consideration of second-line therapy;

d. Without concomitant infection to cause transient CD4 cell decrease.

e. Some experts consider that patients with persistent CD4 cell count <50/mm3 after 12 months on ART may be more appropriate.

f. The optimal viral load value at which ART should be switched has not been defined. However, values of more than 10,000 copies/ml have been

associated with subsequent clinical progression and appreciable CD4 cell count decline.

WHO Clinical Staging Clinical Failure

(CD4 and VL not available)

Immunologic Failure

(VL not available)

Immunologic and Virologic

Failure

(CD4 and VL available)

1 N/A Do Not Switch Consider

Switch

2 N/A Do Not Switch Consider Switch

3 Consider Switch Switch Switch

4 Switch Switch Switch

When to Switch from 1st Line to 2nd Line ARV Regimens

for Treatment Failure

Clinical failure is defined as a occurrence of new or recurrent WHO clinical stage 3 or 4 event (excluding IRIS).

CD4 failure is defined as a fall to (or below) the pre-treatment baseline or a 50% drop from the on-treatment peak level or persistent levels < 100 cells/mm3.

Virological failure is provisionally defined as a plasma HIV-1 RNA level >10,000 copies/ml after a minimum of 6 months on therapy.

ART Failure Meeting: Major Conclusions

Goal of ART in a Public Health Approach: Maximize survival with improved quality of life

Time on ART considered (12 months, 24 months):Clinical: WHO Stage 3 or 4 after at least1 year on ART CD4 : confirmed CD4< 100-200 after 1-2 years (check/reinforce adherence before switching decision)

HIV RNA threshold : Maintain 10,000 as a switch point (little immediate immune damage). Action when VL> 1,000 (adherence, toxicity, drug interaction assessment) and start to consider switching

More efficient use of VL (targeted strategy)Adherence monitoringConfirm immunologic/clinical failure (?discordance)Pregnant women

Use of "alert" criteria (clinical, immunologic and virologic)