Advanced HIV Disease Update: Kenya · 7/17/2020 · The CQUIN Project Virtual Workshop on Advanced...
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Advanced HIV Disease Update:Kenya
Dr Lazarus MomanyiDSD CoordinatorMinistry of Health, NASCOP28 July 2020
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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%)
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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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