Update on Advanced HIV Disease in South Africa
Update on advanced HIV disease in South Africa highlights progress in reducing AIDS-related deaths, prevalence rates, and advancements in coordinating and implementing policies and guidelines for HIV/AIDS response. The report covers statistics on HIV prevalence, ART facilities, mortality rates, and initiatives towards achieving the 90-90-90 targets. It also discusses age and sex demographics of CrAg-positive patients, mortality rates among PLHIV, and leadership coordination for AHD service delivery based on national guidelines.
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Advanced HIV Disease Update: South Africa Letta Seshoka & Mokgadi Phokojoe National Department Of Health 28.07.2020
HIV in South Africa Total Population HIV Prevalence # ART Facilities Mortality Aids related deaths reduced from 30,6% in 2010 to over 15% in 2019 58.78 Million 13.5% Translates to 7.9 million (95%CI:7.1 million - 8.8 million) PLHIV 4 200 (Source: Stats-SA 2019) Number of individuals currently on ART 73% 5 015 476 The CQUIN Project Virtual Workshop on Advanced HIV Disease July 28-29, 2020
HIV in SA Progress towards 90-90-90 The CQUIN Project Virtual Workshop on Advanced HIV Disease July 28-29, 2020 3
AHD in South Africa Age and sex of cryptococcal antigen (CrAg)-positive patients, February 2017 July 2019, South Africa. Prevalence of AHD CrAg-positive patients were predominately men of working age CD4 < 200 = 20,2% CD4 < 100 = 9,8% Reflex CrAg positive = 35 000 (5.8%) from 600 000 screened (between 2017 -2019 Mortality rates amongst PLHIV = Deaths due to HIV reduced significantly from 214 365 in 2009 (accounting for 35.4% of deaths), to 115 167 in 2018(22% of total deaths) Source: NHLS Data, 2019 Source: NICD Bulletin Vol 17 December 2019 The CQUIN Project Virtual Workshop on Advanced HIV Disease July 28-29, 2020 4
AHD Coordination and Leadership AHD service coordination based on the national ART policy guidelines HIV/AIDS Cluster Manager. Dissemination support and implementation monitoring ( Districts/ Facilities. Policy, Guidelines & SOPs Stakeholder Engagement & Oversight Technical Working Group South African National Aids council (SANAC), engaged in coordination of policies and guidelines development, and Coordinate recipients through civil society NGOs/NPOs on HIV & TB strategic plan, policies and guidelines Coordination Support The CQUIN Project Virtual Workshop on Advanced HIV Disease July 28-29, 2020 5
AHD Policies and Guidelines Overarching Country HIV/AIDS Response South African - National Strategic plan on HIV, TB and STIs (2017-2022) National Consolidated HIV treatment guidelines, includes AHD clinical management AGL-SOP - Minimum package of interventions to support linkage to care, adherence and retention in care NDOH HIV/AIDS/TB/ PMTCT & AHD response Training material developed, complete. Plan to conduct national training in August 2020. Due to current COVID-19 pandemic, a 3 days Virtual training underway (face to face takes 5 days) Operationalization The CQUIN Project Virtual Workshop on Advanced HIV Disease July 28-29, 2020 6
AHD Essential Package Clinical package to screen, prevent and treat advanced HIV disease Screening Prophylaxis Cryptococcal screening (reflect CrAg) WHAT Fluconazole pre- emptive prophylaxis Crypto Rx regimen Xpert MTB/Rif TB LAM CPT TPT Identification of TB symptoms at each clinical visit For any inpatient regardless of CD4 or outpatient with TB symptoms and CD4 < 200 (refer to local guidelines as this may be adapted) HIV-pos with a CD4 count <100 cells/ l before initiating ART. - Blood CRAG positive LP CraG negative - Offer for Cryptococcal infection asymptomatic/ symptomatic patients, or Lumber punch positive Signs meningitis LP CraG positive HIV-positive adults and children older than 5 years if CD4 count 200 cells/ L, WHO Stage 2, 3 and 4 TB screening negative WHEN Near POC on site (community site, PHC, hospital) Sample transport to testing site at peripheral hub or central district testing site Hospital /PHC Hospital/PHC/ Community Hospital /PHC/ Community Hospital /PHC/ Community WHERE Laboratory technician, nurse, lay worker Doctor, clinical officer, nurse* Doctor, clinical officer Doctor, clinical officer, nurse* Doctor, clinical officer, nurse* WHO The CQUIN Project Virtual Workshop on Advanced HIV Disease July 28-29, 2020
AHD Essential Package Clinical package to screen, prevent and treat advanced HIV disease Treatment Adherence Support WHAT Test and treat services (Same Day Initiation) Enhanced Adherence Counselling TLD implementation Monitoring of bloods Identification of AHD symptoms at each clinical visit Switch from an EFV- containing regimen to a DTG-containing regimen rapid viral suppression - CD4, routine VL, - according to guidelines - Viral resistance testing - a VL > 1000 c/ml on at least three occasions over two years If non-adherence and if elevated VL WHEN Near POC on site (community site, PHC, hospital) Sample transport to testing site at peripheral hub or central district testing site Hospital / PHC WHERE Laboratory technician, nurse, lay worker Clinician Nurse , CHW WHO The CQUIN Project Virtual Workshop on Advanced HIV Disease July 28-29, 2020
The CQUIN Project Virtual Workshop on Advanced HIV Disease July 28-29, 2020
DSD Models for AHD The CQUIN Project Virtual Workshop on Advanced HIV Disease July 28-29, 2020 10
Components of DSD model for AHD Identifying advanced HIV disease at every facility visit Clinical package to screen, prevent and treat advanced HIV disease as per ART Guidelines Rapid ART initiation and/or regimen switch (2nd and 3rd Line Regimen Switch) Linkage to ongoing care either at PHC/ Hospitals Post initiation/switch follow up and Monitoring The CQUIN Project Virtual Workshop on Advanced HIV Disease July 28-29, 2020
AGL SOP Minimum Package of Interventions AGL - SOP 8 Tracing: Put more emphasis on prioritizing patients initiated on treatment in the last 6 months with Advanced HIV Disease (AHD) within 7 days upon missing appointment or having abnormal results The CQUIN Project Virtual Workshop on Advanced HIV Disease July 28-29, 2020
Laboratory Services: CD4 Testing CD 4 tests are done according to the ART guidelines, and According clinician discretion /request based on clinical assessment Reflex CrAg test done when CD4 <100 Tests are done at laboratory (NHLS ) clinics use courier service system to collect specimen daily, transport to lab and bring back the results Lab track/Online system available to access results The CQUIN Project Virtual Workshop on Advanced HIV Disease July 28-29, 2020 13
Monitoring & Evaluation Data or documentation challenges related to AHD: Lack of HIV resistant testing database at national level, not shared. However, local level results are received to assist in improvement plans and technical support Tier.net system not updated CD4 count <100 at baseline and unsuppressed viral load not addressed on real time. The CQUIN Project Virtual Workshop on Advanced HIV Disease July 28-29, 2020 14
AHD Challenges Area Challenge Covid 19 pandemic has affected the planned activities- as it is a priority Shortage of HR due pandemic Patients fear visiting clinics, leads to presenting late for AHD treatment COVID-19 Unable to conduct face to face clinical trainings Facility Coverage 50-75% of health facilities providing ART have the minimum AHD package available Patient Coverage 50-75% of eligible patients (those with high viral load or newly initiating ART) are screened (with CD4) and provided with the minimum AHD package M&E Systems At least one data element necessary for M&E of AHD is being systematically collected, but elements are not comprehensive (e.g., not all data are included) and/or are not fully integrated into national M&E tools or the national HMIS The CQUIN Project Virtual Workshop on Advanced HIV Disease July 28-29, 2020 15
AHD Priorities for 2020 2021 National Advance Clinical Care (ACC)AHD training package developed and finalized: - Plan Conduct national virtual ACC/AHD training in August 2020, then - Province to cascade the ACC trainings to districts and health facilities. Rationalize M&E Advocate for integration of AHD-related data elements into national M&E tools and the national HMIS for HIV/ART services. Facility Coverage Ensure at least over 75% of health facilities are providing ART have the minimum AHD service package available Patient Coverage Ensure at least over 75% of eligible patients (those with high viral load or newly initiating ART) are screened (with CD4) and provided with the minimum AHD package. Quality of AHD Services Conduct at least one evaluation of AHD services quality using the national quality standards and show impact The CQUIN Project Virtual Workshop on Advanced HIV Disease July 28-29, 2020 16
Acknowledgements Dr. Z. Pinini - NDOH Ms. M. Phokojoe - NDOH Ms. L. Seshoka - NDOH Dr. M. Manganye - NDOH The CQUIN Project Virtual Workshop on Advanced HIV Disease July 28-29, 2020 17
