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The CQUIN Learning Network Lighthouse ALUP and POC VL: Innovations and Experience Eric Auben Mtemang’ombe Lighthouse Trust - Malawi July 17-19, 2017 Harare, Zimbabwe
The CQUIN Learning Network
Lighthouse ALUP and POC VL: Innovations and Experience
Eric Auben Mtemang’ombe
Lighthouse Trust - Malawi July 17-19, 2017
Harare, Zimbabwe
“THELIGHTHOUSE”
• WHOrecognizedCentreofExcellence,worksinclosecoordina9onwiththeMinistryofHealth
• FirstspecialistcentreinMalawiforthecareandsupportofpeoplelivingwithHIVandAIDS
• RegisteredasapublicTrustin2001
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TheLighthouse“Differen9atedCare”
Basedontheprinciplethat“notonesizefitsall”butthatpa9entshavedifferingneedsandrequirements.Examples:
v ALUPPackageofCarev PointofCare(POC)ViralLoadTes:ng
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TheLighthouse“ALUPPackageofCare”
LighthouseusesathresholdofCD4<100cells/mlInterven9ons:v Diagnos(c:ScreenfordisseminatedTB(urine-LAM)anddisseminatedCryptococcalinfec9on(serumCrAg)
v Prophylac(c:Inpa9entswithCD4counts<100theREALITYtrialshowedthatabundleofprophylac9cmeasurescansignificantlyreduceearlymortality
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ALUPPackageofCare
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Lighthouse*+ALUP+Flow+Chart+2.0+
CD4+count+done+for+!any%ART%ini*a*on%!failing%ART%pa*ent%with%high%VL%!sick%looking%pa*ent%on%ART%%Ask+and+look+for:++*Weight+loss+(LOW)+(>10%+or+BMI+<18.5)+*Night+sweats+(NS)+*Chronic+cough++*Shortness+of+breath+(SOB)+*headache,+new+seizures+*oral+candidiasis+*KS+on+legs+or+palate+*frequent+hospital+admission++(>1+admission+in+3+months)+*general+weakness++(needs+assistance+to+walk)+++
CD4%____++
<100+++++OR++100*200+and+paXent+“sick”++
ART+
Urine++LAM+
CrAg+(Serum)+
Albendazol+400mg+od+1/7+
Azithromycin+500mg+od+3/7+
CPT+
neg+
pos+
STOP!%
LP+and++CrAg+(CSF)+
neg+
pos+
Fluco+800+mg+od+2/52+then+Fluco+400+mg+od+8/52+
hold+ART,+admit+to+KCH,++provide+Ampho+for+1/52+
Cough/LOW/NS+absent+
LOW/NS+pos+
Cough/SOB+pos+
FASH+
INH+300+/Vit+B6+25+mg+3/12+
TB+treatment+
TB+treatment+
TB+treatment+
INH+300+/Vit+B6+25+mg+3/12+
KS+on+legs,+mouth,+…+pos+
neg+
pos+
neg+
STOP!%
pos+
neg+ INH+300+/Vit+B6+25+mg+3/12+
Date:+_______________+Pat.+Name:___________++Pat+ID:______________+Clinician:____________+
Do+as+appropriate:++1) Sputum+Xpert++2) Treatment+with+amoxyl+500+
mg+tds+5/7+++azithromycin+500+mg+3/7+and+review+
3) CXR+
TB+proven+or+probable+
TB+improbable+
Weight:+______+Height:+______+BMI:_________+ TF+
>17+
<17+
STOP!%
Refer+for+chemotherapy+
Refer+for+“Fundoscopy+CMV+reXniXs+screen”+STOP!%
CMV+pos+
CMV+neg+
Gancyclovir++i.o.+
Howimmunosuppressedareourpa9ents?v ResultsfromLighthouse1.1.2017-15.4.2017
(approx.100newini9a9ons/month,and4,000visits/month)v TotalCD4countsdone424(=approx.120/month)
v Fornewini9a9ons:236pa9ents(55%)v 1-6monthonART:7pa9ents(2%)v 6-12monthonART:15pa9ents(4%)v >12monthonART:119pa9ents(32%)
v Newini9a9ons:236=>CD4>100:181(77%)/CD4<100:55(23%)
WHOStage >100 <=100
IorII 122 27
IIIorIV 30 19
Total 152 46
Lighthouse ALUP
• In depth analysis of 66 patients with CD4 count <100: – No O.Is (CPT, Albendazole, Azithromycin, IPT) 37 (56%) – TB diagnosed 14 (21%) – Cryptococcemia 8 (12%) – Cryptococcal meningitis 6 (9%)
– KS 1 (1%)
Viralloadmonitoring
• Malawi’sNa9onalHIVprogramreliesonmonitoringofViralLoad(VL)tomonitortreatmentsuccess– Thisis“rou9neVL”monitoring,“targetedVL”
• CurrentVLturnaround9meis~3months• Posesasubstan9alproblemwhendealingwithtargetedsampleresults,whichmayen9ceanimmediateclinicalac9on
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PointofCareViralLoadMonitoring
• SupportfromfromtheBill&MelindaGatesFounda9on(BMGF)enabledLighthousetoprocureplalormsandcartridgesforPOCVLtests(GeneXpertHIVquant)
• ThePOC-VLmachineallowsLighthousetoprocess10-20VLsamplesperday
• Thishaschangedtheapproachto“failing”pa9ents
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LighthousePOCVL
• ThePOC-VLtestisrequestedusingadedicatedrequestform(“blueforms”)
• Onthisformtheclinicianspecifiesamongstotherdatathereasonforthetestaswellthe9meintervaltoreceivingtheresultandtheac9onthatheorshetakesinresponsetotheresult.
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LighthousePOCVLreportforJan-May,2017
Currentresults:GeneralPOCtestsdone
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LighthouseTotaltest–machinestatus 581Successful 537(92%)Errororaborted 44(8%) Ofthosesuccessfully,Sampletype 537POC-VL 529(99%)
POC-EID 8(1%)
LighthousePOCVL
POC-VLtestswithrequestsdocumented
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Comment:Thepropor9onofpa9entswithavailabledataonthereasonsandac9onsislowerthanthetotalnumberoftestsrun.Thisisexpectedinarou9neopera9onsasformshavemul9plepossibili9estogo“missing”.Thepropor9onof62%atLighthouseliesintherangewemayhaveexpected.
Pa9entswithavailablePOC-VLrequestinforma9on(“blueform”)
359(62%)
ClinicssendingPOC-VLsamples LighthouseClinic 259(72%)KCHward 29(8%)N-CAP 71(20%)
LighthousePOCVL
VLStatus Low(<1,000copies)
High(>1,000copies)
Total
VLresults 100 144 244
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VLstatusforall“blueforms”whichwerereturnedfordataentry.
LighthousePOCVL
“Ac9on”takenonhighresult LH(n=144)Referralforadherence 15(10%)
Switchto2ndline 87(60%)Noac9on 3(2%)Other 3(2%)
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POCVL:TimefromorderingVLto“Ac:ontaken”@Lighthouse
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Ac9ontaken
LowVLresult
HighVLresult
All
Sameday 43(66%) 70(69%) 113
Nextday 13(20%) 16(16%) 29
Later 9(13%) 15(14%) 24
Total 65 101 166
Comment:Outof359withblueforms,166had9meanddateof“ac:ontaken”documented
LighthousePOCVLProblemsandwayforward• Thebiggestopera9onalproblemliesinthesupplychain
managementofcartridges.AsLHistheonlyclinicinthecountrydoingthetestonalargerscale,thesupplieronenhasnostockavailableinthecountry
• Ini9allytheexpectednumberofteststopurchasewasunclear,soitwasdifficulttoes9matethedemand.Internalslowprocurementprocessalsoaddedtotheseobstacles.
• Nowinabeperposi9ontopredicttheexpecteddemand,weexpectthisproblemtobelessrelevantinthefuture;currentlya6monthssupplyhasbeenreceived.
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LighthousePOCVL
Themainproblemfromaninves9ga9onalsideisthelowreturnofforms.
– Solu9on:Thedatamanagerwillgeneratealistofpa9entswhohadatestdoneandthefilesofthepa9entswillbeassessedasitisassumedthatasubstan9alnumberofformswere“filed”awaywithoutrecording.
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Thank you!
