peter saranchuk, md tb-hiv adviser southern africa medical unit (samu)
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Scaling Up Retinal Screening in an HIV clinic in Nanning, China to prevent blindness from CMV retinitis . Peter Saranchuk, MD TB-HIV Adviser Southern Africa Medical Unit (SAMU) Operational Centre Brussels (OCB) Médecins Sans Frontières (MSF). Advances and Opportunities to - PowerPoint PPT PresentationTRANSCRIPT
Scaling Up Retinal Screeningin an HIV clinic in Nanning, China
to prevent blindness from CMV retinitis
Peter Saranchuk, MDTB-HIV Adviser
Southern Africa Medical Unit (SAMU)Operational Centre Brussels (OCB)
Médecins Sans Frontières (MSF)
Advances and Opportunities to Address CMV retinitisSatellite SymposiumIAS Conference30 June 2013
HIV late presenters
31.8%
Of people present for the first time with a CD4 count < 200 cells/µL
CMV: The 3rd most common/serious OI
Prior to Nov 2008 in Nanning
Problem: Diagnosis of CMV usually delayed
– Retinal screening not done– Diagnosis made only after vision loss had
already occurred– Irreversible– Required referral to a secondary hospital
Poor Outcomes (prior to Nov 2008)
• Of 17 patients assessed in Nov 2008 and found to have active or inactive CMV retinitis:– 5 (29%) had bilateral involvement– 7/11 eyes (64%) with inactive disease were
blind*
* <20/400 visual acuity and/or able to count fingers at 10 feet
Solution
Training in retinal examination
•
Over 4days
• By an ophthalmologist (D. Heiden)• Of HIV clinicians• In the use of an indirect ophthalmoscope (IO)• E-mail address given for follow-up support
Ophthalmoscopy
The key to both = use dilating drops
IndirectDirec
tVs.
After Nov 2008 in Nanning
•Retinal screening–Performed routinely– In all at-risk patients (e.g. those with CD4<100)– By HIV clinicians– Using an indirect ophthalmoscope– In the HIV clinic
CMV retinitis has a typical pattern
After Nov 2008
• Now able to diagnose CMV retinitis:– At the first visit– Within minutes– Inexpensively– At primary HIV care level– More easily than other common, serious OIs!
After Nov 2008
• Now able to diagnose CMV retinitis:– At the first visit– Within minutes– Inexpensively– At primary HIV care level– More easily than other common, serious OIs!
•= A point-of-care diagnostic!
Every HIV clinic should have…
• A bottle of drops to dilate pupils• E.g. Tropicamide
Ophthalmologists still involved
• Telemedicine– E-mailing of digital retinal images
• Complicated cases– Immune Recovery Uveitis (I.e. IRIS)– Retinal detachment
After Nov 2008• Routine retinal screening• Earlier diagnosis• Earlier treatment • Improved visual outcomes
– E.g. Minority of patients now being diagnosed with CMV retinitis are blind
Subsequent Trainings
Average duration of treatment in Nanning
~4.5 months
N.B.: ART needs to be initiated as soon as possible
Usual Treatment: Sticking needles into eyes!
Price of valganciclovir needs to be…
<1 dollar per tablet
to prevent CMV-related blindnessand encourage retinal screening
Conclusions1. Retinal screening performed routinely
prevents CMV-related blindness2. Can be done by trained HIV clinicians
– In resource-limited settings3. Diagnosis of CMV retinitis then becomes
easier than other OIs!4. Need a treatment which is both
convenient and affordable
Acknowledgments
• Dr. David Heiden• Pacific Vision Foundation• Seva Foundation• Chinese partners
–Guangxi CDC–The Fourth Hospital of Nanning
Treatment options in Nanning
• Intravitreal injections (weekly)– Inexpensive– Barbaric!
• I.v. ganciclovir (daily)– Expensive– Inpatient vs. outpatient?
• Oral valganciclovir (VG)– Convenient– Outrageously expensive (~40 USD per tablet)