Advanced HIV Disease Update: Kenya · 7/17/2020 · The CQUIN Project Virtual Workshop on Advanced...
Transcript of Advanced HIV Disease Update: Kenya · 7/17/2020 · The CQUIN Project Virtual Workshop on Advanced...
Advanced HIV Disease Update:Kenya
Dr Lazarus MomanyiDSD CoordinatorMinistry of Health, NASCOP28 July 2020
The CQUIN Project Virtual Workshop on Advanced HIV Disease July 28-29, 2020
HIV in Kenya
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• Overall prevalence 4.9% (F: 6.6%, F: 3.1%)
• Heterogeneity of HIV burden by geography and population; 70% of infections found in 9 high burden counties
• PLHIV, 1.3 million adults, 139,000 children
• 36,000 new infections amongst adults /year (incidence; 0.14%)
The CQUIN Project Virtual Workshop on Advanced HIV Disease July 28-29, 2020
HIV in Kenya: Progress Towards 90-9090
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KENPHIA 2018 Preliminary Report
• Good progress towards attainment of ‘second 90’ across all age groups
• Gap in attainment of ‘first 90’ across all age groups (particularly low knowledge of HIV status amongst adult males)
• Viral suppression amongst children still a challenge
The CQUIN Project Virtual Workshop on Advanced HIV Disease July 28-29, 2020
• Approx. 30% of newly enrolling PLHIV in Kenya have Advanced HIV Disease
• Kenya has recorded a 55% reduction of AIDS-related deaths since 2010, from 56,000 deaths in 2010 to 25,000 deaths in 2018 (UNAIDS estimates)
AHD in Kenya
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31%
69%
CD4 Count at Enrollment (Jan - Dec, 2019)
CD4 (<200 cells/mL) CD4 (>200 cells/mL)
Data from NDWH
The CQUIN Project Virtual Workshop on Advanced HIV Disease July 28-29, 2020
AHD Coordination and Leadership
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NASCOP
National Clinical TWG
Regional Care & Treatment TWGs
Facility Multi-Disciplinary Teams (MDTs)
• NASCOP; development of policy, guidelines for AHD
• Manager Care and Treatment Unit focal person for AHD implementation
• Involvement of PLHIV at national TWG, Sub-CoE level
• National and regional TWGs provide technical support for implementation of AHD care
National Clinical TWG DSD Sub-CoE
The CQUIN Project Virtual Workshop on Advanced HIV Disease July 28-29, 2020
AHD Policies and Guidelines
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• The Kenya national ART guidelines define package for management of AHD
• Kenya has also developed a Differentiated Care Operational guide that further defines DSD models
• Both documents are undergoing review - expand/refine models o DSD including for AHD
The CQUIN Project Virtual Workshop on Advanced HIV Disease July 28-29, 2020
AHD Essential Package - Kenya
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• Aim: reduce morbidity and mortality• Kenya guidelines recommend:
o Mx at any ART SDP/all facility level/home visits may be required if unable to come to facility
o Initial Mx and ART initiation by trained and experienced HCW
o Consultation with MDT , TWG, mentors, and senior clinicians as needed
o Referral to a higher-level facility when feasible if consultation is not adequate to stabilize the patient
Intervention Who? CD4 Count
Sputum Xpert® MTB/ RIF
Recommended test for TB diagnosis among ALL symptomatic PLHIV
Any CD4 count
TB-LAMPLHIV with advanced diease, severely ill, admitted
≤100 cells/mm3 , any for severely ill
Cryptococcal Ag Screening
Adolecents & adults≤100 cells/mm3 , any for severely ill
Cotrimoxazole Prophylaxis
All PLHIV Any CD4 Count
TB Preventive Therapy/TPT
TB Asymptomatic PLHIV, newly enrolling
Any CD4 count
Fluconazole Pre-emptive Rx
Adolescents, adults SCRAg Positive with no symptoms of CM
<100 cells/mm3
ART Initiation
Test and Treat
All PLHIV. Deferred in CM, PTB (closely monitor for IRIS in patients with advanced disease, with comorbidities)
Any CD4 count
Prophylaxis and Pre-emptive Treatment
Diagnosis
The CQUIN Project Virtual Workshop on Advanced HIV Disease July 28-29, 2020
• > 300 CD4 testing labs (conventional platforms/PoC) in the country
• Most County referral hospitals have testing capabilities (PT supported by National HIV Reference Labs)
• General decline of CD4 testing in Kenya after adoption of ‘test & treat’ in 2016, availability of VL monitoring
• Guideline recommendation for CD4 testingo All new clients at baselineo Repeat testing for clients on fluconazole proph. for
cryptococcal meningitis
• Current challenges; o ‘missed’ testing at baseline o Low reporting rates for tests done o Shortages of controls/reagents for some of the platforms
Laboratory Services: CD4 Testing
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-
10,000
20,000
30,000
40,000
50,000
60,000
70,000
Jan-18
Mar-18
May-18
Jul-18
Sep-18
Nov-18
Jan-19
Mar-19
May-19
Jul-19
Sep-19
Nov-19
Jan-20
Mar-20
May-20
CD4
TEST
S RE
PORT
ED
MONTH
CD4 Tests Reported, through Kenya DHISJan 2018 - May 2020
The CQUIN Project Virtual Workshop on Advanced HIV Disease July 28-29, 2020
Some of the challenges:• Incomplete documentation of baseline
assessments (CD4, WHO staging) in patient charts, EMRs
• Country yet to adopt longitudinal registers for tracking outcomes for AHD
• Categorization, AHD indicators not routinely reported through KHIS
• National aggregation dashboard to track outcomes for RoC with AHD not yet available
Monitoring & Evaluation
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The CQUIN Project Virtual Workshop on Advanced HIV Disease July 28-29, 2020
DSD Models for AHD
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WhatPackage of Care for AHD as defined in the ART Guidelines
WhereART FacilityReferral for complicated cases
WhoExperienced HCW, Referral to senior clinician, MDT/RTWG
When> Weekly follow-up until ART initiation> 2, 4 wks after ART initiation> monthly until confirmed VS
People with AHD who have not achieved Viral Suppression after ART initiation are managed within the ‘Viremia’ Clinics
The CQUIN Project Virtual Workshop on Advanced HIV Disease July 28-29, 2020
National Support for Clinicians
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• An innovative national support platform for clinicians through;o email consultationo toll free phone consultation
(0800724848)
• Clinicians able to consult on difficult cases including treatment failure, comorbidities etc
The CQUIN Project Virtual Workshop on Advanced HIV Disease July 28-29, 2020
Challenges
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ART Initiation 2nd 90
• Significant number of PLHIV presenting with AHD at enrollment / return to care after default
• Sub-optimal/inconsistent assessment of PLHIV for AHD at enrolment, follow up
• Limited capacity of HCWs on management of AHD, comorbidities
• Unavailability of harmonized M/E tools, standardized SOPs for AHD
The CQUIN Project Virtual Workshop on Advanced HIV Disease July 28-29, 2020
• Expand/refine the AHD package in the planned revision of the 2018 ART Guidelines, Differentiated Care Operational Guide
• Capacity building of HCWs on management of AHD ; National Advanced HIV Clinical Course (NAHCC)
• Review/adopt national AHD SOPs• Design and disseminate IEC/literacy on AHD for
PLHIV• Review M & E tools for AHD
Priorities for 2020 - 2021
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The CQUIN Project Virtual Workshop on Advanced HIV Disease July 28-29, 2020
• Ministry of Health NASCOP• Global Fund, PEPFAR • Regional Technical Working Groups• Implementing Partners• Facility HCWs• NEPHAK
Acknowledgements
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