HIV Drug Resistance in the WHO African Region

Transcription

1 Steering Committee meeting Geneva, Switzerland HIV Drug Resistance in the WHO African Region Rui Vaz HIV Program Manager WHO Regional Office For Africa (AFRO) 1

2 Inter-country Support Teams ICST Country Coverage 63 NPOs in 33 / 46 countries 21 HIV/AIDS Officers in 21 countries West 1 (17) Algeria Benin Burkina Faso Cape Verde Côte d Ivoire Gambia Ghana Guinea Liberia Mali Mauritania Niger Nigeria Senegal Sierra Leone Togo Guinea-Bissau The 3 IST created Harare 10/11 International staff Ouagadougou 7/9 Libreville 8/9 ICST Location Regional Office Central (11) South- East (18) Angola Burundi Cameroon Central African Republic Chad Botswana Comoros Eritrea Ethiopia Kenya Lesotho Madagascar Malawi Mauritius Dem Rep. Congo Equatorial Guinea Gabon Rwanda Sao Tome and Principe. Congo Mozambique Namibia South Africa Seychelles Swaziland Tanzania/Zanzíbar Uganda Zambia Zimbabwe 2

3 HIV/AIDS Program Organizational Structure Common Areas 1. Medicines and Supplies 2. Laboratory 3. Partnerships and Resource Mobilization 4. Community based interventions 5. Secretaries HIV/AIDS AFRO Brazzaville 1. Strategic Planning Officer 2. Treatment, Care, Support 3. Paediatric Care 4. Surveillance and SI 5. Prevention 6. Testing & Counselling ATM HIV/AIDS Program Manager Administration 1. Management Officer 2. Administrative Assistant 3. Secretary Administrative support 1. Administrative Officer 2. Financial Assistant 3. Program Assistant 4. Secretaries IST Eastern & Southern Africa IST Central Africa IST West Africa Planning and Development Officer Treatment, care and support Laboratory Surveillance Testing and Counseling Sexually Transmitted Infections Prevention Nursing & Community Care Data Manager HIV Drug Resistance Male Circumcision Administrative assistant Secretaries 3 NPOs & IPOs Planning and Development Officer Treatment, care and support Laboratory Surveillance and SI Public Health Specialist Administration and Finance Monitoring and Evaluation Prevention HIV Drug Resistance Secretaries NPOs & IPOs Planning and Development Officer Treatment, care and support Surveillance and SI Laboratory Prevention, Nursing & community Care Public Health Specialist Administration and Finance Monitoring and Evaluation HIV Drug Resistance Secretaries NPOs & IPOs

4 Progress : Southern/Eastern Africa 4 Fatim Cham, Ph.D. HIV Laboratory Technical Officer WHO IST/ESA Harare Zimbabwe

5 Background Level of implementation of the HIVDR strategy Funding HIVDR laboratory Network HIVDR database Country Progress Report Summary, Sub regional Meeting, October , Dar-Es-Salaam Tanzania 5

6 Rapid scale up of ART in resource limited countries (RLC) is an international priority (UNGASS 2001) Reduction in cost of ARV as well as increased funding made possible through WHO, PEPFAR, WB, MAP, GFATM and several other organizations In Sub-Saharan Africa, the number of people receiving ARV therapy increased from < 0.1 million in 2002 to 2.1 million in 2007 (UNAIDS) Eastern and Southern Africa HIV Prevalence : (GP) 23% ; (ANC) 40 % % of patients in need have access to ARVs 6

7 WHO recommends a public health approach to ART delivery and management in RLC - Standardized 1 st and 2 nd line regimens supports adherence and limits HIVDR WHO advocates and supports countries in systematically implementing the global HIVDR assessment elements. 12 /18 countries within the Eastern and Southern Africa sub region are: starting or are in the process of implementing at least one of the elements of the HIVDR assessment and prevention strategy using tools and protocols recommended by WHO 7

8 Key : In italics Countries implementing one or more elements of the strategy Underlined Countries not yet implementing the strategy 8

9 Level of implementation of the HIVDR strategy Country HIVDR WG EWI Prevention surveys HIVDR- Threshold surveys HIVDR database Accredited genotyping laboratories Botswana * Ethiopia + Kenya Malawi Mozambique * Namibia South Africa Swaziland Tanzania Uganda Zambia Zimbabwe Total 11/12 7/12 5/12 12/12 6/12 3/ applied for WHO accreditation * Preparing for application for WHO accreditation

10 Articles reporting results : 1. HIVDR transmission surveys from 5 countries from the sub region published - Malawi, South Africa, Swaziland, Ethiopia, and Tanzania 2. HIV drug resistance early warning indicators (EWI) pilot - Malawi 3. Publication by Ndembi et al entitled Antiretroviral drug resistance surveillance among newly diagnosed women attending antenatal clinic in Entebbe, Uganda AIDS Research and Human Retroviruses 2008; 24(6):

11 Geographic Area Year Sites N Subtypes Prevalence category Addis Ababa 2005 ANC 39 C, AG <5% Lilongwe 2006 ANC 54 1 C <5% Gauteng Province Gauteng Province Manzini- Mbabane 2002 ANC 65 C <5% 2004 ANC 48 C <5% ANC 61 C, B <5% 3 Dar-es-Salaam 2005 ANC 50 1 A, C, D <5% Entebbe 2006 ANC 46 A, D, C <5% 11 1 DBS 2 2 with NRTI mtns 3 2 with PI mtns

12 Country 12 FUNDING/SUPPORT Gates via WHO/AFRO CDC/PEPFAR Spanish Gov t GFATM NGO/Universities/EU Zimbabwe Zambia Kenya Malawi South Africa Tanzania Ethiopia Mozambique Uganda Namibia Swaziland Botswana Total 10/12 12/12 1/12 5/12 12/12

13 4 laboratories in the sub region are WHO accredited for HIVDR genotyping 1 Regional: South Africa (NICD, Joburg- accredited to use In house assay ONLY/Plasma) 1 Affiliated: South Africa (Joburg, CLS- accredited to use Viroseq assay ONLY/Plasma) 2 National o o Kenya (Kisumu, CDC- accredited to use Viroseq assay ONLY/plasma) Uganda (MRC- UVRI accredited to use In house assay ONLY/plasma) Countries are in consultation with sub regional office for price negotiations with accredited laboratories. 13

14 HIVDR v.1 software available free of charge In depth Training conducted in Malawi (Aug 2008) Brief orientation conducted in Aug/Sept 2008 in Swaziland and Zimbabwe Recently, Hands-on introductory demonstrations held and software distributed to all countries during the Dar-es-Salaam meeting. 14

15 Dar-es es-salaam, October participants from 14 countries Tanzania, Mozambique, Botswana, Namibia, Zambia, Swaziland, Kenya, Uganda, Malawi, Lesotho, Zimbabwe Ethiopia, Ghana and Nigeria Participants/country involved with the HIVDR strategy included : a) HIV drug resistance epidemiologists or HIV M&E focal point or HIV surveillance focal points, b) Head ARV Clinician or national ART Program Managers, c) Reference Laboratory virologist or laboratorian, d) WHO HIV Program Officers e) CDC officer 3. Support from WHO IST/ESA, WHO HQ and CDC 15

16 1. To provide an overview of the HIVDR assessment elements and to introduce new tools that support the HIVDR assessment elements of the strategy. 2. To allow countries to report their progress, share experiences, and discuss plans for the future 3. To provide training on: The HIVDR database Use of the WHO Sequence Quality Assessment Tool; additional laboratory quality assurance procedures Protocol adaptation and annual report writing Supporting and Monitoring Adherence 16

17 Country EWIs HIVDR Prevention Surveys HIVDR-Threshold Surveys Botswana Plans in progress Plans in progress 2005 & 2007: Gaborone /Francistown ANC/Plasma Prev: <5% Ethiopia Apr Sept pilot sites EWIs: 1, 2, 3, : pilot site= 1 Plan = 10 sites 2005: Area: Addis Ababa/ANC/plasma Prev: <5% 2008: 3 Areas planned Kenya Mar May 07 Plan: 12 pilot sites EWIs: 1, 2, 3, 5 Plan : 3 pilot sites Approval pending 2005: Nairobi/ANC/DBS/DPS Prev: <5% Nov-Dec 08: ANC /DBS planned for Kisumu and Nairobi Malawi Oct Dec public sector sites EWIs: 1, 2, 3, 6,7 2008: pilot sites = : 6 new sites/yr 2006 :3 sites in Lilongwe Prev : <5% 2008: same sites in Lilongwe and sites in Blantyre 17

18 Country EWIs Mozambique Sept Dec 2007 Pilot in 12 sites EWIs: 1, 2, 3. 4, 6 HIVDR Prevention Surveys 2008: Pilot 2 sites 1.Pediatric: Oct in progress (113 recruited) 2.Adult : pending ethical approval 2009: 2 additional sites 2010: 7 provincial Hosps HIVDR-Threshold Surveys 2006 surveys in Sofala-Beira and Maputo Preg. women /DBS stored Plan 2009/10: Manpula, Sofala- Beira and Maputo Namibia Plan: EWIs 1, 3. 4, 5 6 Plan: Pilot in 4 adult and 1 pediatric site Swaziland Pilot data collection in 3 sites EWIs:1, 2, 3, 5, : 3 pilot site (2 adult/1 pediatric) 2009: 2 additional sites 2006 survey: Windhoek Prev : <5% based on 34 sequences 2006 survey : Mabane-Manzini Prev : <5% 2008 ANC survey : Mabane- Manzini Aug Oct 2008 : 73 plasma collected Genotyping to be done at NICD SA Tanzania May EWIs: 5 sites Plan: Pilot in 5 sites 2006 survey: Dar-es-Salaam ANC/DBS Prev : <5% July October 2008 survey: Mbeya and Mwanza ANC/DBS 18

19 Country EWIs HIVDR Prevention Surveys HIVDR-Threshold Surveys Uganda July pilot: 41 sites EWIs: 1, 2, 3. 4, 6 Plan new sites + 41 sites Plan : 4 sites 2009: 6 sites 2010: 6 sites 2011: 8 sites Ethical approval pending 2007: Entebbe/ANC/plasma Prev : <5% Zambia Plan 2008: capture 7 EWIs from SmartCare cards 2009: Plan to pilot in 4 sites Plan 2008 ANC/DBS Zimbabwe Pilot August 07 EWIs: 20 sites 2008: 40 sites 2008: Plan to pilot in 3 sites 2006 survey : Harare /ANC/DBS not genotyped 2008 Approval pending 19

20 Standardized national 1 st and 2 nd line regimens Electronic Pharmacy and Medical record systems Guidelines for counseling prior to start of ART Drug quality assurance: Use of WHO pre-approved drugs Standardized minimum information elements in all ART medical records; patient and cohort monitoring Central procurement of ARVs to prevent stock-outs Adherence support and monitoring to minimize loss to follow- up Operational research on alternative specimen collection formats Strong commitment by Government and health care workers to implement the WHO HIVDR strategy 20

21 1. Protocol adaptation and review of HIVDR strategic plans and proposals 2. Monitoring progress and situational analysis of the level of implementation of national HIVDR plans 3. Support in training and for developing National HIVDR database 4. Capacity building for WHO accreditation of national laboratory 5. Negotiations with accredited laboratories for genotyping and viral load 6. Support with Global fund proposal development 21

22 Thank you 22

23 HIV DR in CENTRAL AFRICA Pr Belabbes AFRO / IST Central Africa In collaboration with WCO Angola, WCO Cameroon and OCEAC 23

24 COUNTRIES COVERED BY THE INTERCOUNTRY SUPPORT TEAM / CENTRAL AFRICA Angola Burundi Cameroon Central African Republic Chad Congo Democratic Republic of Congo Equatorial Guinea Gabon Rwanda Sao Tome & Principe 24

25 25 A global view of HIV infection 33 million people [30 36 million] living with HIV, 2007

26 ESTIMATED NUMBER OF PEOPLE LIVING WITH HIV Country Estimate [low estimate high estimate] [ ] Angola [ ] Burundi [ ] Cameroon Central African Republic [ ] [ ] Chad [ ] Congo Democratic Republic of Congo Equatorial Guinea Gabon Rwanda Sao Tome&Principe [ ] [ ] [ ] [ ] 26 Source: 2008 Report on the global AIDS epidemic, UNAIDS/WHO, July 2008.

27 ART COVERAGE IN CENTRAL AFRICA Country Angola Burundi Cameroon Central African Republic Chad Congo Democratic Republic of Congo Equatorial Guinea Gabon Rwanda Sao Tome&Principe Estimated number of People Receiving ART Estimated number of People Needing ART Estimated ART Coverage Source: Towards Universal Access: Scaling up priority HIV/AIDS Interventions in the Health Sector, Progress Report 2008, WHO/UNAIDS/UNICEF.

28 STP ART Coverage in Central Africa Cameroon CAR Chad Congo DRC Eq Guinea Gabon Rwanda Countries Série1 Burundi Angola Percentage

29 Evaluation of transmitted HIV drug resistance among ART-naive patients in Central Africa A sub regional Network for HIV DR Survey in Central Africa was created on 2006 under the coordination of: AFRO OCEAC IRD Montpelier (France) National Reference Lab CRESAR/IMPM/IRD Yaoundé, Cameroon 29

30 Evaluation of transmitted HIV drug resistance among ART-naive patients in Central Africa CEMAC / OCEAC Countries were involved Cameroon Chad Congo Equatorial Guinea Gabon RCA However Equatorial Guinea and Gabon didn t collect samples for unknown reasons 30

31 Evaluation of transmitted HIV drug resistance among ART-naive patients in Central Africa The study was conducted according to the WHO Protocol for evaluation of transmitted HIV drug resistance using specimens from HIV sentinel sero surveys in resource-limited settings with slight changes The study is now completed and the results will be released soon during a joint AFRO / OCEAC meeting 31

32 Evaluation of transmitted HIV drug resistance among ART-naive patients in Central Africa The main issues recorded were The absence of an HIV sentinel sero survey on the sites of the study The difficulties to collect eligible samples in each site The overload-work by the staff who claimed a specific allowance The high cost of this study 32

33 CAMEROON HIV DR Project The National HIVDR Strategy Working Group was constituted The group meets every week A six month plan to implement the HIV DR strategy has been elaborated A protocol of assessment of HIV DR EWI has been elaborated and will be soon finalized and implemented 33

34 CAMEROON HIV DR Project The National Reference Lab CRESAR/IMPM/IRD Yaoundé is already selected for serological tests, viral load and genotyping This lab is accredited by WHO as National HIVDR Laboratory for the year (reviewed on last June 2008) To fill a financial gap during the 5 coming years, NAC agreed to integrate HIV DR on the component of the Cameroon application to the GFATM Round 9 34

35 CAMEROON HIV DR Project Activities funded and to be implemented up to December 2008: To finalize the 5 year plan and to validate the protocol of HIV DR transmission threshold survey and the protocol of HIV DR monitoring To assess the EWI in 10 hospitals with a high rate of patients recruiting To start the HIV DR survey among a cohort of 130 patients under ART to be recruited in Yaoundé 35

36 ANGOLA HIV DR Project Objectives To strengthen the national capacity and WCO in managing the ARV resistance To strengthen the national capacity in HIVDR laboratory testing To strengthen the national capacity in monitoring the HIVDR emerging during treatment in ART sentinel sites To evaluate the transmitted HIV drug resistance 36

37 ANGOLA HIV DR Project Guidelines of the WHO (primary, secondary resistance, EWI etc.) have been translated into Portuguese in May 2008 WCO Angola will organize a session on key steps and proceedings for implementation of WHO guidelines The implementation of the HIV DR project is waiting the MoH clearance 37

38 IST CENTRAL AFRICA PLANNING Advocacy for establishment in each country a National HIVDR Working Group Provide technical assistance to support implementation of the WHO HIV DR protocols (EWI, threshold survey, monitoring) Support the HIV DR Prevention activities 38

39 IST CENTRAL AFRICA MAIN CONSTRAINTS Lack of funds to conduct and implement the activities HIV DR activities are often not funded by the MOH s Insufficiency of human resource in the sub region Very few skilled laboratories in the sub region Only one WHO accredited National HIV DR laboratory in the sub region Difficulties to collect a reliable information in most countries 39

40 THANK YOU MERCI OBRIGADO 40

41 WHO HIVRESNET STEERING COMMITTEE MEETING, November 04 05, 2008 Geneva, Switzerland Progress : West Africa Dr GERSHY-DAMET GUY-MICHEL REGIONAL ADVISER FOR HIV LABORATORY COORDINATOR FOR HIVDR REGIONAL OFFICE FOR AFRICA 41

42 IST-WA: Population in 2007 Number of districts 1523 Total Population Bill Gate Spanish fund Ghana; Burkina Faso Senegal Source: EPI report 42 42

43 ,0% 4,5% 4,0% 3,5% 3,0% 2,5% 2,0% 1,5% 1,0% 0,5% 0,0% HIV PREVALENCE BY COUNTRY IN ,7% 4,4% 4,4% 2,8% 1,9% 1,7% 1,6% 1,5% 1,5% 1,3% 0,8% 0,7% 3,2% HIV prevalence Ben in Burkina Faso Cape verde Côte d' Ivoire Gambia Ghana Guinée G uinée Bissau Liberia Mali Mauritanie Niger Nig eria Sén égal Sierra L eone Togo Algérie

44 Nombre de PVVIH par pays en ,000,000 2,500,000 2,000,000 1,500,000 1,000, ,000 0 Algérie Benin Burkina Faso Cape verde Côte d'ivoire Gambia Ghana Guinée Nombre de PVVIH 10, ,000 1, , , ,000 5, ,619 66,392 2,851, ,983 Guinée Bissau Liberia M ali M auritani e Niger Nigeria Sénégal Sierra Leone Togo 44 44

45 Algérie Benin Burkina Faso Cape verde Côte d'ivoire Gambia Ghana Guinée Guinée Bissau Liberia Mali Nombre de PVVIH sous ARV en 2006 Nombre de PVVIH sous ARV en 2007 Mauritanie Niger Nigeria Sénégal Sierra Leone Togo Pays Nombre de PVVIH

46 Togo Sén égal Sierra L eone Nig eria Mauritanie Nig er Côte d'ivoire G ambia G hana G uinée G uinée Bissau Liberia Mali Cape verde Burkina Faso Ben in Algérie % 35% 30% 25% 20% 15% 10% 5% 0% Estimate coverage ART Country C o v e r a g e A R T ( % )

47 REGIONAL PROGRESS Regional workshop on surveillance and monitoring HIVDR in Africa region Windhoek, Namibia, December 11-13, 2007 outcomes Existing practice in monitoring HIV resistance to ARV drugs in the t African region Documented. Agreement on recommendations following the data of countries. Potentialities of partnerships for the implementation of the HIVDR activities in the countries and the regional level. Discussed. Draft regional annual HIVDR report Prepared. Agreement on the next steps for surveillance and monitoring HIV drugs resistance in the region PARTICIPANTS (59): were laboratory experts, and epidemiologist countries: South Africa, Botswana, Cameroon, Chad, Congo, Ethiopia, Kenya, Malawi, Mozambique, Namibia, Nigeria, RCA, Swaziland, Tanzania, Uganda, Zambia and Zimbabwe. Cosponsor PHAC-ASPC Canada; CDC ; PharmAccess; IRD France 47 47

48 SUBREGIONAL PROGRESS Sub regional briefing of the francophone countries of West African countries on HIVDR strategies Ouagadougou, Burkina Faso, mai 2008 Outcomes Briefing of francophone countries on HIVDR strategies for prevention of drug resistance Participants (35): Clinician;epidemiologist, virologist in charge of HIVDR program Countries: Cote d Ivoire, Guinée; Guiné Bissau; Cap Vert;Mauritania; Burkina Faso; Niger;Benin; Togo; One laboratory have so far been assessed for accreditation in SENEGAL 48

49 HIVDR SURVEILLANCE AND MONITORING IN WEST AFRICA SUB REGION BENIN Country Monitoring EWI HIVDR-TS BURKINA FASO P C IP COTE D IVOIRE p C IP GHANA IP C C Guinea Mali Senegal P C Togo Nigeria IP C IP P IP IP 49

50 COTE D IVOIRE National HIVDR working group formed Plan for collection of HIVDR EWI Plan for HIVDR threshold survey to assess transmitted resistance among ANC EWI Briefing of Staff 19 May 08 Collect of data in 14 sites from 21 May _19 june 08 Data acquisition 2 june 08 Preliminary report in preparation Threshold Survey Briefing of trainers november 2007 Briefing of health staff november Specimens collection from 5 sentinelles urban site in Abidjan: jan 08 Transfert of plasma to reference Lab every day. - Supervision of the difference sites from 30 march to 10 april 08 On the five sites 2 completed 3 in progres FSHKB Blokaus : 231 -PMI HG Yop. Attié : 505 -FSU Delafosse : 367 Future Plans: Establish HIVDR database Initiate HIV drug resistance monitoring surveys by end 2008 Strengthen in-country laboratory capacity 50 50

51 GHANA National Expert Committee on HIV HIV Drug Resistance sub-committee HIV Drug Resistance Plan and Protocols Assessment of HIV DR Survey sites Provision of equipment and consumables to selected HIVDR sites from HIV DR Budget SOPs/Checklist for HIVDR and surveillance and monitoring Training for participants from selected HIVDR survey sites site ART Coordinator appointed to monitor the procedure for sample collection to ensure that errors are minimized. Sites for EWIs covers the entire country 10 sites All ten regional hospital involved in the EWIs In Ghana, seven (7) EWIs used Threshold Survey Five Sites for the HIV Drug resistance survey Blood samples were collected between Jan 2008 and Dec 2008 Monitoring of emergence: Target per site: 130 clients=130 samples Atua :60 samples Agomanya: 130 samples Koforidua regional Hospital: 67 Korle-Bu teaching Hospital: 61 Komfo Anokye teaching Hospital:43 Conclusion HIV DR survey is on-going Analysis will be completed by end of year 51 51

52 BURKINA FASO National HIVDR working group formed Plan for collection of HIVDR EWI Plan for HIVDR threshold survey to assess transmitted resistance among ANC Early Warning Indicator Number of sites : 9 in all the country Number of indicators : 4 (EWI.1, EWI.2, EWI.3 & EWI.4) Data analysis : in progres Threshold Survey Number of site more than 10 in Ouagadougou Number of sample collected 6000 Collection will be completed by end november 08 Strengthen in-country laboratory capacity Future Plans: Establish HIVDR database Initiate HIV drug resistance monitoring surveys in

53 CHALLENGES Funds to systematically implement all aspect of the national HIVDR plan. Human resource issues : Drs, nurses, pharmacy, data clerks Approval process for HIVDR protocol Inadequate supply of ARVs, OI drugs and other supplies Incomplete Medical and Pharmacy records Patients and specimen flow in busy ARV clinics Limited infrastructure for transport of specimen in country Access of patients to ARV: transport, cost, Pharmacy hours Provision of technical support in resistance monitoring to the majority of countries. Trained pool of consultant Ensuring and maintaining a coordinated QA/QC system that will guarantee quality resistance monitoring Translation of various protocol in official languages (French, Portuguese) 53 53

54 WAY FORWARD Training of consultants on the HIVDR strategy for provision of timely support to countries Partners should provide timely responses to proposals submitted for approval Establishment of reference laboratories in the region Develop a regional database on HIV resistance monitoring Assist Countries to have harmonized database for HIV resistance monitoring. Frequent visits to countries to assess the level of implementation Workshop for analyzing and interpreting the sub regional EWI results first quarter HR strengthen at sub regional level from the Bill and Melinda Gates Foundation grant Advocacy for HIVDR in the RC

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