10 July 2018

Zimbabwe: Decentralising HIV Diagnosis Bears Fruits

"We can now easily switch our clients from one drug to another. Once a client walks into our institution, we can quickly check for their viral load count and take necessary intervention immediately," says Leonard Nyakabau, an HIV focal person at Hauna District Hospital in Manicaland.

Mr Nyakabau said previously, they were losing patients as the disease progressed while awaiting viral load confirmation from a centralised laboratory.

It took up to three months to get that confirmation.

He said a person living with HIV cannot be switched from one drug to another without knowing their viral load despite them presenting with opportunistic infections.

Hauna is one of 25 resource-constrained district hospitals in the country that benefited from the 100 Samba point of care machines used for viral load testing and early infant diagnosis (EID) under a Government decentralisation project launched last year.

Manufactured by Diagnostics for the Real World (DRW) in partnership with Cambridge University and funded by the Global Fund to Fight Aids, Tuberculosis and Malaria, the new Samba II point-of-care machines are specifically meant for resource-limited settings.

Before the rolling out of the first phase of the decentralisation project, institutions such as Hauna District Hospital would send their blood samples to a conventional laboratory in Mutare where they took up to three months before being returned, impacting negatively on treatment outcomes as some clients were lost to follow ups.

Hauna district medical officer, Dr Caephas Fonte said this arrangement resulted in high volumes of sample rejections, lost samples and ultimately delayed treatment thereby compromising effective HIV management.

He said samples had a time-frame within which they should be processed before they are rendered useless. If the time-frame is exceeded the samples will no longer be useful.

Dr Fonte said because of transport challenges, some samples took time to reach the central laboratory, resulting in rejections.

He also said for Hauna, all samples from the 21 clinics in the district were first transported to the district hospital, from which they would be conveyed to Mutare for processing. In Mutare, he said, the samples would be processed together with samples from seven other districts in the province, thereby increasing chances of getting lost.

"We are supposed to be doing routine viral load testing, ideally after every six months and those that seem to be failing we usually do testing after every three months and that should be associated with adherence counselling," said Dr Fonte.

"However, because of delays associated with getting samples to Mutare, many samples were getting lost on the way or were rejected resulting in further delays to offer alternative treatment to patients."

He said with decentralisation of viral load testing, they can now do routine testing and offer necessary interventions timely.

He said a reading of less than 1 000 copies means the person is responding well to treatment while a reading of more than 1 000 copies means the person is failing anti-retroviral drugs and might need to be switched to another combination.

"Right now I have three patients admitted, they are all HIV positive. They came with different conditions and faced with such a scenario, one question that comes to mind is, are we failing on ART, what could be the problem.

"However, we did viral load tests on the three and two of them have viral load of less than 1 000 copies meaning they are doing well on ART, so what they are having could just be one of those infections which anyone can have and we are managing them. However, the other one has a viral load of over 1 000 copies and we are beginning to ask questions around adherence to medication or he could have developed drug resistant HIV. This has all been possible with this decentralisation programme. Previously it would take us up to three months to make such determinations," said Dr Fonte.

Furthermore, he said, every pregnant woman who is HIV positive, is supposed to get a viral load check to manage vertical transmission of HIV to her unborn baby.

"A pregnant woman's viral load is important in classifying a child as a high risk or just a risk baby. Just a risk baby is given nevirapine prophylaxis and a high risk baby is given a dual combination so we need to make that decision because it makes prevention of mother to child transmission (PMTCT) successful," said Dr Fonte.

He said Government should actually distribute more machines to the districts to meet the high demand of samples coming from clinics as it was contributing to successful HIV management.

Hauna district hospital medical laboratory scientist Mr Patrick Simbi described the machines as ideal for resource-constrained countries like Zimbabwe in managing HIV.

Mr Simbi said when they started using the machines, they ran comparative tests between the point of care machines and the centralised machines and results compared well.

"All the samples we sent to Mutare for confirmatory results matched with results produced by the point of care machines. What was invalid here was also invalid there. What was below a 1 000 copies here was also less than a 1 000 copies there.

"However, the advantage of point of care machines is that they produce results on the same day unlike the previous system where results would take several weeks before they are returned," said Mr Simbi.

He said on a daily basis, they process an average of 12 samples, giving a maximum of about 250 samples a month.

Mr Simbi said the point of care machines were the way to go and should be cascaded to all clinics to ensure even hard to reach sites benefit from the service.

He also called on Government to quickly implement early infant diagnosis (EID) - a test that is run by the same machine to determine the HIV status of an exposed baby.

Mr Simbi said this service was also much needed but was still not available because of lack of reagents to run it resulting in samples for EID being sent to central laboratories, where they also take a long time before they are returned.

"We also need to do EID as a matter of urgency because of these issues of missing results and rejections. You will find that with EID, from each batch we send for processing, we miss a result. Considering that the patient would have waited for almost two months, it then complicates effective management of paediatrics," he said.

Before the decentralisation project, infant HIV diagnosis was centralised to conventional laboratories in Harare, Bulawayo and Mutare.

The machines used at these laboratories were big and required skilled manpower and enough space, which could not be found in smaller health institutions at district levels.

Director for Laboratory Services in the Ministry of Health and Child Care Mr Douglas Mangwanya said decentralisation of viral load testing had impacted positively on HIV treatment outcomes.

He said previously, with the centralised system, the number of people living with HIV who accessed viral load testing stood at 15 percent but has now gone up to 70 percent.

Mr Mangwanya said because of this success Government was now looking forward to go into the second phase of this decentralisation targeting more district hospitals in the country.

He said they were also working on expanding early infant diagnoses to all district hospitals currently offering viral load testing.

"The National Aids Council is working on procurement of the reagents for early infant diagnoses and once these are available delays encountered in diagnosing exposed babies would be a thing of the past," said Mr Mangwanya.

According to the Ministry of Health and Child Care, slightly above 50 percent of children with HIV are on treatment and diagnoses of the children was one of the reasons cited for the low uptake of paediatric treatment.

Similarly, a number of people living with HIV are failing to get viral load tests on time due to few testing machines, a situation that also complicates tracking of progress to treatment in line with national targets of ensuring that all those on treatment have their viral load suppressed to undetectable levels.

Zimbabwe

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