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%)


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


• 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


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


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


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


• > 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


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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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


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


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


• 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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• Ministry of Health NASCOP• Global Fund, PEPFAR • Regional Technical Working Groups• Implementing Partners• Facility HCWs• NEPHAK

Acknowledgements

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advanced hiv disease update: kenya · 7/17/2020 · the cquin project virtual workshop on advanced...

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