updates

2. Narrative (Part I)
of
Clinical Workshop on HIV & Hepatitis
(attended in KTM on NOV 20-22, 2018, organized by WHO & NCASC)
by:
Dr. Pawan KB Agrawal,
MBBS, MDGP (IOM, Maharajgunj), Distance Fellowship in Diabetes Management (CMC, Vellore)
Consultant, General Practice & Emergency, Nyaya Health Nepal-Possible
8th January, 2019, Tuesday

3. Objectives
• General
• To disseminate HIV & Hepatitis B & C guidelines for building capacity of the
program managers at national & provincial level
• Specific
• To review the national progress on testing and treatment for HIV and
Hepatitis
• To provide updated recommendation on HIV and Hepatitis testing and
treatment

5. “ENDING AIDS EPIDEMIC BY 2030”
Fast Track Targets
Indicator 2016 2020 2030
HIV new
infection
1,800,000 500,000 200,000
HIV deaths 1,000,000 500,000 400,000
ART
coverage
19,500,000 30,000,000 33,000,000

6. Nepal’s perspective
• First HIV diagnosed in 1988
• Estimated number: 31,020
• HIV prevalence in general population <1% and in KPs <5%.
• New HIV infections: 835
• HIV related deaths: 1,306
• Source: NCASC, 2017

7. Nepal’s perspective
• 73 ART sites in 59 districts by Jul 2018
• ART dispensing sites in rest of the districts except Rukumkot.
• 16,428 (out of 31,020) currently under ART.
• Source: NCASC, 2017

9. National HIV Strategic Plan
• Targets 90-90-90 by 2020 and 95-95-95 by 2030
•90%of people with HIV known their status
•90% of people who know their status are on ART
•90% of people on ART achieve viral suppression

12. National HIV Strategic Plan
• Eliminate vertical transmission of HIV
• Eliminate congenital syphilis
• Reduce 75% of new HIV infections

13. Key achievements
• Reduction of HIV prevalence in general population
(0.55% in 2005 to 0.15% in 2017)
• Reduction of HIV prevalence in PWID (68% in 2002 to
8.5% in 2017)

14. Pertaining facts from NDHS 2016
• 81% women & 98% men have heard of HIV
• 72% women and 92% men are aware of STI
prevention using condom.
• 34% women and 58% men know where to seek for
their HIV status.

15. Key Population
• Six as per National HIV Strategic Plan
• Relative risk:
FSW, TG 13X < PWID 22X < MSM 28X
• Only one third of overall prevalent infection in KPs
• However, two thirds of new infection are seen in KPs
• Remarkably low levels of access to HIV treatment & prevention
among KPs

16. Key Population
• PWID
• MSM
• TG
• Female Sex Workers
• Male Sex Workers
• Labor Migrants

17. Contributors to AIDS Epidemic
• Dwindling international funding and NGOs
• Inequities in budget allocation for KP targeted programs
• Lack of local data
• Enormous time loss between data collection and action
• Restrictive laws and policies towards KPs Stigma
Loss of access to prevention, screening and treatment

19. How to curb the epidemic??
• Identification of key population
• Combination prevention
• Strengthening of HIV screening, treatment and viral load suppression
• Enabling environment
• Strategic information generation and dissemination
• Financial sustainability

20. Increase access to screening
• Community based approaches
• Partner testing
• HIV self testing
• Testing narrative needs to change from
“everybody has the right to refuse a test” to
“everybody has the right to test”

21. Task sharing in screening
• A fundamental approach to ensure universal health coverage.
• National HIV Strategic Plan (2016-21) mentions that “Nepal will roll
out HIV screening by trained lay providers (TLPs) to increase HIV
testing among key population”
• The TLPs should belong to community of interest.
• Major role of TLPs:
• screening,
• ensuring referral for confirmation,
• supporting clients in access to ART and thereafter continuation
• perform under supervision of a lab assistant

29. • HIV DNA PCR is used for early infant diagnosis.
• For those infected before and during birth, the sensitivity of the test
is 40-50% in the first 48 hours of life, 90% at 14 days of age and >95%
at six weeks of age.
• Samples for DNA PCR can be collected in DBS paper specialized for
nucleic acid

30. Access & Quality of ART
• Treat all
• ART distribution by TLPs as well
• Better adherence
• Cost NPR 30,000/month in 1998 to NPR 1000/month at present
• 32 pills to 1 pill per day (TDF 300 + 3TC 300 + EFV 600 containing FDC at
bedtime)
• Better drugs with reduced side effects are available over the time.
• Monitoring of treatment

33. Dolutegravir
• Approved in 2013
• Showed earlier viral suppression ( 4 Vs 12 wks)
• Improved side effect profile
• Low incidence of resistance.
• Effective in pregnancy as well (signals of NTD
have been generated however)

35. Pre exposure prophylaxis
• Recommended for
• People at substantial risks
• Serodiscordant couples
• Client whose partner are hesitant to start ART
• MSMs
• FDA approved in 2012
• WHO recommendation in 2016

37. Pre exposure prophylaxis
• Relative risk reduction ranges from 44% to 86% in different studies.
• TDF alone or in combination with 3TC or FTC are recommended
• Regimen: TDF 300 + FTC 200 daily X 90 days

40. Pre exposure prophylaxis
• Indication
• HIV negative
• Seropositive spouse without viral suppression
• Multiple sexual partner
• Hesitancy to use condoms
• History of postexposure prophylaxis
• On request

41. Pre exposure prophylaxis
• Contraindications
• HIV positive
• CrCl <60ml/min
• Acute HIV infection with recent exposure to HIV
• Allergy to PrEP regimen
• Side effect
• 1 in 10 have nausea, abdominal cramps and headache which resolve over the
duration of first month.
• 1 in 200 may have Cr elevation (reversible on discontinuation)

43. Path ‘PMTCT’ to ‘EMTCT’
• MTCT rate of HIV <2% in non breast feeding and <5% in breast feeding
populations. AND
• A case rate of new pediatric HIV infection due to MTCT of ≤50 cases
per 100,000 live births.
• A case rate of congenital syphilis of ≤50 cases per 100,000 live births.