Update on Advanced HIV Disease in Zambia: Prof. Lloyd Mulenga Shares Insights

Prof. Lloyd Mulenga, Director for Infectious Disease at the Ministry of Health in Zambia, provided an update on Advanced HIV Disease (AHD) in the country. The update includes progress towards the 95-95-95 target, prevalence of AHD, mortality rates among PLHIV, coordination of AHD services at the national level, and existing policies and guidelines for AHD in Zambia.

• HIV
• Zambia
• Advanced HIV Disease
• Prof. Lloyd Mulenga
• Ministry of Health

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1. Advanced HIV Disease Update: Zambia Prof. Lloyd Mulenga Director for Infectious Disease Ministry of Health 18thJuly 2020

2. HIV in Zambia Progress towards 95-95-95 94.1 93.1 94.7* * VLS rate calculated based on number of suppressed out of tests done in Q12020 and the full cascade can only be done annually at close of the year 2

3. Advanced HIV Disease (AHD) in Zambia What is known about the prevalence of AHD? 17% Tx_New has CD4 cell count < 200 cell/ L 30% of Tx_Curr has CD4 cell count <200cells/ L (ZamPHIA 2016) 5% of PLHIV on treatment are on 2nd line ART 0.3% of PLHIV on treatment are on 3rd line ART The CQUIN Project Virtual Workshop on Advanced HIV Disease July 28-29, 2020 3

4. Advanced HIV Disease (AHD) in Zambia What is known about mortality rates amongst PLHIV? Estimated mortality rate for the year 2020 among PLHIV of 17,284 (Spectrum estimates) TB leading cause of death followed by cryptococcal meningitis Estimated Mortality on HIV Treatment among Active Patients and Patients Lost to Follow- up in 4 Provinces of Zambia: Findings from a Multistage Sampling-Based Survey CB Holmes, et al. PLoS Med. Jan 2018; 15(1) Despite ART scale-up in Zambia, there were high and substantially (3-9X) under-reported rates of mortality among those on ART between 2013-2015 o10-20-fold higher than treated patients in Europe oHighest in the 1st months of treatment, but also high longer-term (after stability on ART) The CQUIN Project Virtual Workshop on Advanced HIV Disease July 28-29, 2020 4

5. AHD Coordination and Leadership How are AHD services coordinated at national level? Is there a technical working group and/or focal person? AHD services are coordinated as part of ART services and fall under the HIV TWG with a Task Force on AHD There is a focal point person To what extent are recipients of care/people living with HIV engaged in coordination, policy development and guidelines related to AHD? ROCs are engaged in the development of guidelines for AHD The CQUIN Project Virtual Workshop on Advanced HIV Disease July 28-29, 2020 5

6. AHD Policies and Guidelines Is there a national AHD strategy? No specific strategy exit to reduce incidence or outcomes of AHD but reduction of mortality due to HIV is enshrined in the NSP Are there national AHD guidelines? Advanced HIV Guidelines are at developmental stage Are there national training materials related to AHD? Training materials under development The CQUIN Project Virtual Workshop on Advanced HIV Disease July 28-29, 2020 6

7. AHD Essential Package What is the essential package of AHD diagnostic and treatment services? WHO package of care for AHD has been adopted in the Zambia consolidated guidelines includes baseline CD4/LAM/CrAg testing and prophylaxis with CTX and Fluconazole in applicable cases At what level of the health system are these provided? All level of care are supposed to provide these services, but the implementation has been staggered with the level 1 ( district ) hospital and above being prioritised The CQUIN Project Virtual Workshop on Advanced HIV Disease July 28-29, 2020 7

8. Laboratory Services: CD4 Testing How and where are CD4 tests done in Zambia? All health care facilities provide CD4 cell count testing CD4 cell count is done at initiation to ART, and then at 6mo and every 12mo for those with baseline CD4cell count <350 cells/ L Monitoring of CD4cell count is discontinued after 2 consecutive CD4cell count >350 cell/ L CD4 cell count monitoring is recommenced whenever there is unsuppressed viral load The CQUIN Project Virtual Workshop on Advanced HIV Disease July 28-29, 2020 8

9. Monitoring & Evaluation Are there data or documentation challenges related to AHD? There is no specific monitoring system or indicators for AHD The HIA-3 designed to record in-hospital conditions is suboptimal making is difficult to measure the real incidence of AHD The CQUIN Project Virtual Workshop on Advanced HIV Disease July 28-29, 2020 9

10. Update on CHAI AHD Project 1 At global level, the Unitaid-CHAI AHD Initiative aims to address barriers and reduce morbidity and mortality while also improving cost efficiencies, by accelerating access to affordable, optimal products for preventing, testing and treating key opportunistic infections Of people initiating ART in Sub-Saharan Africa have AHD Challenge: There is an ineffective global response to advanced HIV disease (AHD), and an urgent need to accelerate access to critical, life-saving products for diagnosis, prevention, and treatment of AHD. 1/3rd CHAI Implementation Period: Jan 2019 Dec 2020* *Costed Extension under review Unitaid-CHAI Advanced HIV Disease Initiative Accelerate product introduction and build demand for AHD commodities through catalytic procurement and adoption and rollout support Reduce the price of priority health products through supply-side market interventions Coordinate procurement and provide market visibility for AHD commodities The AHD project is supported by a strong coalition of partners, including Global Fund, PEPFAR, EGPAF, and MSF. Unitaid is calling on all partners to contribute to these efforts to prevent needless HIV deaths The CQUIN Project Virtual Workshop on Advanced HIV Disease July 28-29, 2020 10

11. Update on CHAI AHD Project con. At national level, through the pediatric HIV program, CHAI is supporting MoH to improve overall pediatric HIV management for infants and children aged 0-14 years including adolescents 15-19 years. 2 Challenge: The 2020 Zambia Consolidated Guidelines (ZCGs) for Treatment and Prevention of HIV provide guidance for management of AHD. Monitoring compliance to guidelines and quality standards is done through Service Quality Assessments (SQA). However the SQA tools were not aligned to the latest guidelines for enhanced management of pediatric HIV including AHD. Revision of Pediatric ART SQA tool to align with 202O ZCGs Scale-up Pediatric ART SQAs using revised tool Strengthening Pediatric HIV Service Delivery through: o Capacity building of MoH multi-disciplinary teams of HCWs at all levels (national, sub- national and service delivery points) in conducting service quality assessment to monitor adherence to quality of care standards and identifying service delivery gaps o Ensuring that clinical monitoring is done according to guidelines; WHO Clinical staging CD4 and Viral Load monitoring Management of unsuppressed viral load (EAC and repeat VL testing) Drug resistance testing to inform actions taken including switching to appropriate regimen o Pediatric HIV Management and DSD Trainings and Clinical mentorship WHO clinical staging Treatment failure Management of AHD o Scaling up DSD Models including for unstable ROCs CD4<200uml, Stage 3 & 4 and those presenting with AHD o Use of SQA Dashboard and narrative to summarize findings to aid interpretation and use of findings to develop remedial measures including targeted trainings and clinical mentorship The CQUIN Project Virtual Workshop on Advanced HIV Disease July 28-29, 2020 11

12. DSD Models for AHD and P@HR AHD and P@HR are managed in facilities 1. Viraemic clinics for ROC with unsuppressed viral load focus is on enhanced adherence counselling (EAC) 2. Advanced Treatment centres for third line ARV regimen The CQUIN Project Virtual Workshop on Advanced HIV Disease July 28-29, 2020 12

13. Additional Perspectives from National Network of People Living with HIV There are still PLHIV who present themselves late with advanced diseases before starting HIV treatment Screening of advanced diseases is a challenge on PLHIV in rural and peri urban health facilities, due to delayed results, stock outs of CrAg rapid test for meningitis and lack of point of care CD4 tests for AHD patients Inadequate trained health personnel to conduct testing for diseases on patients with AHD in remote areas. The CQUIN Project Virtual Workshop on Advanced HIV Disease July 28-29, 2020 13

14. Challenges Inadequate testing for HIV Drug Resistance (Genotype) Lack of certain drugs Rifabutin for TB treatment Flucytosine for Cryptococcal meningitis treatment Inadequate experts to comprehensively manage these cases The CQUIN Project Virtual Workshop on Advanced HIV Disease July 28-29, 2020 14

15. Priorities for 2020 2021 Finalising the guidelines Guidelines roll out and training Weekly ECHO for AHD Introduction of Rifabutin, Flucytosine The CQUIN Project Virtual Workshop on Advanced HIV Disease July 28-29, 2020 15

16. Acknowledgements MOH HIV Unit DSD Unit CHAI Jansen EGPAF CQUIN The CQUIN Project Virtual Workshop on Advanced HIV Disease July 28-29, 2020 16