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  • Through BCC activities to the community people, knowledge/approval-positive (KA+) people come out.
    These people turn into intention/practice-positive (IP+) people through further motivational activities.
    And they go for VCT service.
    Through counseling and testing they get to know their HIV status.
    For seropositive people, medical and health care services should be provided.
    These include basic health care and nutrition advice, clinical care for opportunistic infection, home-based care,
    MTCT prevention for a seropositive pregnant woman, ARV drug treatment if available.
    Vaccine development is always a hope for the people living with HIV/AIDS.
    Psychological, legal, social, spiritual, and economic support are also important for the person.
    With these support, they are able to positively live with HIV/AIDS.
    Some of them may even disclose their HIV status and take active role to educate other people, share their experiences with the community people, abd advocate for their human rights.
    For seronegative people, BCC again takes important role to maintain their changed-behavior.
    Some people may even take active role to educate the fellow community members and motivate people to change their behaviors and to go for VCT.
    These advocacy-positive (A+) people take important role to mitigate stigma and discrimination toward people living with HIV/AIDS.
    More people are motivated to change behaviors and practice safer sex or abstain.
    This is a client-centered model for total management of HIV/AIDS. VCT is the key strategy of this model.
    Keeping the flow of a client is crucial.
  • wwwn.cdc.gov/dls/ila/cd/zambia/files/role-labs.ppt

    1. 1. ValueValue of Laboratoryof Laboratory TestingTesting inin TheThe Care and Treatment of HIVCare and Treatment of HIV PatientsPatients Francis Kasolo, MBChB, MSc, Ph.D, DTM& H. Consultant Virologist.
    2. 2. Presentation Outline • HIV infection is Zambia • laboratory involvement in the care of PLWHA • Way forward • Conclusion
    3. 3. Background Information
    4. 4. HIV: The Zambian Situation • HIV is a leading cause of deaths among Zambians. • At the end of 2001, 1.2 million Zambians were estimated to be living with HIV/AIDS. • Over half of these infections are in women. • An estimated 20,000 Zambians died of AIDS in 2001- Underestimate.
    5. 5. HIV: The Zambian Situation • In the 2001-2002 DHS reported that: – HIV prevalence is almost twice as high in urban as in rural areas. – 17.8% women aged 15-46 were HIV positive. – 12.9 % men of the same age were HIV positive. • Sentinel populations show significant increases in infection rates over time. – In Lusaka and Ndola, HIV prevalence among women attending antenatal clinics increased from 5% in 1985 to 27% in 1994. – This rate then dropped to 18% in 2001.
    6. 6. Medical & Health CareCommunity + - KA+ people People positively living with HIV/AIDS A+ BCC BCC BCC A+ Remember Labs role in theRemember Labs role in the Continuum ofContinuum of Care For HIV/AIDSCare For HIV/AIDS Spiritual Support Social Support Economic Support Psychological S/C Legal Support Clinical Care (O.I. Treatment) Basic health care / nutrition advice Home-based Care MTCT Prevention ARV Drug Treatment Vaccine Trial Confidential/Anonymous VCTVCT IP+ People Traditional leaders Religious leaders Schoolteachers Parents Youths Men/Women Vulnerable people IEC/BCC
    7. 7. Role of Laboratory In the ManagementRole of Laboratory In the Management ofof PLWHAPLWHA  Laboratories are involved at several levels of HIV/AIDS Care and treatment. • Initiation of therapy. • Monitoring of Therapy. • Monitoring of Side effects. • Monitoring of Drug resistance. • Investigating Emergence of New OI While on ARVS.
    8. 8. What Laboratory Tests Are WeWhat Laboratory Tests Are We Talking About?Talking About? • Virological tests • Immunological tests • Haematology assessment • Clinical chemistry assessment • Opportunistic infection screening Bacteriology, parasitology, mycology etc
    9. 9. 1.1. Initiation of TherapyInitiation of Therapy
    10. 10. Laboratory Diagnosis for HIV InfectionLaboratory Diagnosis for HIV Infection Screening Test Negative Positive Positive-Confirm +ve 2nd Test 3rd Test IndeterminatePositive Negative Antibody Assay (Serial Testing)-OMS II Negative
    11. 11. Abbott LCx HIV Quantitative RNA Assay (LCx) Bayer(formerly Chiron) Quantiplex HIV RNA bDNA Assay version 3.0 (bDNA) Organon Teknika NASBA NucliSens HIV-1 QT Assay(Nuclisens) P24 antigen assays as alternative to viral load Roche Amplicor HIV-1 Monitor Assay version 1.5 (Monitor) HIV Viral Load Estimation.HIV Viral Load Estimation. Quantitative methodologiesQuantitative methodologies
    12. 12. CD4 Estimation.CD4 Estimation.  Flow cytometry Technology  Microscopy based Technology I.e. Dynabead technology  ELISA based Technology
    13. 13. Additional Investigations • Hematological assessment  e.g. Hgb, WBC, • Bio-Chemical assessment  Liver enzymes  Renal funcition • Hepatitis screen  (HCV, HBV) • Screen for opportunistic infections/Malignacies  Tuberculosis, PCP, Histology for KS, CACx
    14. 14. When Should We Start Therapy- laboratory Perspective
    15. 15. HIV (copies/ml) 200 350 55,000 CD4 (/ml) Treatment Recommend treatment Observe process Observe process or recommend treatment Where Comprehensive Lab FacilitiesWhere Comprehensive Lab Facilities Are Available and AffordableAre Available and Affordable Symptomatic Phase: Treatment Asymptomatic Phase:
    16. 16. WHOWHO Recommendation onRecommendation on InitiationInitiation ofof TherapyTherapy (In Resource Poor Countries).(In Resource Poor Countries). • If CD 4 testing unavailable:  WHO stage IV disease irrespective of total lymphocyte count  WHO stage II or III disease with a total lymphocyte count <1,200 /mm (1,200 lymphocytes approx.200 CD4 /µl)  WHO stage I delay initiation of therapy
    17. 17. 2.2. Monitoring Response toMonitoring Response to ARV TherapyARV Therapy
    18. 18. 2.2. Monitoring Response to ARVMonitoring Response to ARV TherapyTherapy • Frequency 0, 1, 3, 6, 9, 12 • Hematological monitoring  Hgb, WBC • Bio-Chemical monitoring  Liver & Renal • Immunological & Virological monitoring  Viral Load, CD4 & Drug Resistance testing
    19. 19. 3.3. MonitoringMonitoring Side EffectsSide Effects Attributable to ARV DrugsAttributable to ARV Drugs
    20. 20. 3.3.MonitoringMonitoring Side EffectsSide Effects Attributable to ARV DrugsAttributable to ARV Drugs NARTI Lactic acidosisLactic acidosis AZT: Zidovudine Bone marrow inhibition 3TC: Lamivudine d4T: Stavudine Neuritis ddI: Didanosine Diarrhea ddC: Zalcitavine ABC: Abacavir Anaphylaxis NNARTI NVP: Nevirapine Hepatitis, Rash EFV: Efavirenz Central nerves system DLV: Nelavirdine PI SQV: Saquinavir RTV: Ritonavir Liver obstruction IDV: Indinavir Urolithiasis (kidney stones), NFV: Nelfinavir Diarrhea APV: Amprenavir Rash LPV/r: Lopinavir/ritonavir
    21. 21. 4. Monitoring Possible Emergence of ARV Drug Resistance
    22. 22.  CD4+ lymphocyte decrease  Increase in VL from undetectable levels despite compliance  Clinical failure e.g. emergence of new OI & un-explained loss of weight When Should One SuspectWhen Should One Suspect Emergence of ARV Drug ResistanceEmergence of ARV Drug Resistance??
    23. 23. Mutated Position of Reverse TranscriptaseMutated Position of Reverse Transcriptase by RT Inhibitor Treatmentby RT Inhibitor Treatment (amino acid position)(amino acid position) Drugs Mutated position ZDV M41L D67N K70R L210W T215F/Y K219E/Q ddI M41L K65R D67N T69A/S K70R L74V V75T M184V/I L210W T215Y K219Q ddC K65R T67D L74V V75T M184V/I T215C 3TC E44D V118I P157S M184I/T/V d4T M41L I50T D67N V75T I178M T215Y K219Q ABC M41L K65R D67N K70R L74V Y115F M184V L210W T215F/Y K219Q NVP A98G L100I K103N V108I Y181C/I Y188C/L/H G190A DLV K103N/T Y181C P236L EFV A98G L100I K101E K103N V108I V179D Y181C Y188L G190S P225H
    24. 24. 5.5. Investigating Emergence ofInvestigating Emergence of New OI While on ARVSNew OI While on ARVS • It is important to remember that Laboratories are critical in investigating emergence of OI e.g TB, PCP, etc
    25. 25. What Is the Way Forward? • Acceptance of the fact that not all our facilities will perform all the required investigations need to support ART • Creation of a three level laboratory network
    26. 26. What Is the Way Forward?  Primary level- Minimum requirements to initiate & monitor therapy (e.g. Hgb, WBC, LFT, U/E) +/- Microscopy based CD4 testing.  Secondary level- Primary level plus simpler technologies for CD4 estimation.  Tertiary level- Comprehensive laboratory facilities (Viral load, resistance testing- Centers of excellence).  Ensure a coordinated QA/QC system that willEnsure a coordinated QA/QC system that will guarantee quality HIV testing and ARTguarantee quality HIV testing and ART monitoring.monitoring.
    27. 27. Conclusion • The laboratories are a key component in the management of patients on ARV. However.However. • Comprehensive laboratory support in the management of patients on ARV is expensive (Approx. 200 US$ plus/year).
    28. 28. Conclusion • This will affect the way therapy is monitored esp. in Zambia. • Highly technical investigations e.g. drug resistance testing, are not available in all facilities. • There is need to establish a national laboratory network to support ART.
    29. 29. Since this picture was taken there has been a newSince this picture was taken there has been a new addition-addition-Thank YouThank You