HIV in the Haematology laboratory in South Africa: Challenges and Poten<al Solu<ons

Transcription

1 HIV in the Haematology laboratory in South Africa: Challenges and Poten<al Solu<ons Dr Jessica Opie University of Cape Town & NHLS SOUTH AFRICA ISLH Milan 2016

2 Talk Outline HIV in South Africa Socioeconomic and health care disparifes Role of Haematology laboratory Huge demand for HIV related haematology tests Wide spectrum of laboratory infrastructure and skills Status of Point of Care tesfng Haematological complicafons of HIV Cytopenias Lymphoma Safety of our blood supply Going forward

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4 South African Townships 20 years aner apartheid Extreme poverty sfll affects many Worsened by increasing populafon migrants and refugees Here infecfous disease and crime are rife

5 South Africa at a Glance Total populafon > 55 Million 45% of South Africans live on US$2/day Official unemployment 25.5% Top 10% of South Africans earn majority of total annual income Severe Socioeconomic and Health disparifes

6 HIV pandemic in South Africa > 6,4 Million living with HIV Of adults years, 16.6 % are HIV +ve Highest HIV burden in the world ARV therapy insftuted from 2004 In 2015 ~ 3.1 Million on anfretroviral therapy (ARV) TB leading cause of death for HIV +ve (UNAIDS Global report 2013) HIV & TB tesfng 30-40% of public health sector laboratory expenditure

7 Impact of HIV on Haematology Laboratory : 1. CD4 tesfng & haematological monitoring Huge demand ~ 4 million CD4 counts performed annually Majority from ARV clinics CD4 count guides when to start ARV therapy Vast majority of CD4 tests performed in large central labs Haemoglobin (POC: HemoCue Hb201), FBCs (centralised) Diagnosis of haematological complicafons of HIV.

8 NaFonal Health Laboratory Service Prof Wendy Stevens, WITS, NHLS NaFonal Priority Program 80% of our populafon relies on state health sector/nhls NHLS trains all pathologists and technologists

9 CD4 tesfng in the centralised laboratory Panleucogate methodology introduced in Single plajorm, two colour flow (CD45 and CD4) Bead Count rate for IQC (detects pipemng errors) Affordable, relafvely simple operafon & training Accommodates high workloads (500/day at GSH) Good performance in EQA FC500 Cell Mek (Beckman) 1. Glencross DK et al Large- scale affordable PanLeucogated CD4 tes1ng with proac1ve internal and external quality assessment: in support of the South African na1onal comprehensive care, treatment and management programme for HIV. Cytometry Part B 2008;74B (Suppl. 1): S40 S51. (Paediatric CD4 ranges: Shearer WT et al: Lymphocyte subsets in healthy children from birth through 18 years of age: the Paediatric AIDS Clinical Trials Group P1009 study. J Allergy Clin Immunol 2003; 112(5): Adult CD4 ranges from Albany Medical Centre).

10 CD4 Point of Care TesFng POCT technology rapidly growing segment of diagnosfc industry 1:4 tests in developing world Growth in POCT driven by HIV and TB CHALLENGES: increased staffing, high costs, clinics with poor infrastructure eg unstable power supply, high temperatures, lack of LIS connecfvity PIMA (Alere) currently candidate Fingerprick or venous blood, 20 minute TAT Single use cartridge with dried reagents 24USD/test incl material, labour, equipment and IQC

11 DiagnosFc challenges of HIV in the haematology laboratory Cytopenias Anaemia commonest mulffactorial (ACD, drugs, HIV itself) Parvovirus B19 induced PRCA ITP, TTP Pancytopenia Advanced HIV Bone marrow pathology (disseminated TB, malignancies) Haematological malignancies Most common: High grade NHL (DLBCL, Burkip, Burkip- like) Hodgkin lymphoma

12 RetrospecFve review of 147 cases High diagnosfc yield Unique diagnoses in 33% Disseminated MTB and ITP most common diagnoses made, followed by malignancies

13 Bone Marrow trephine findings in disseminated tuberculosis Ziehl Neelsen stain H and E a b 53 year old man with advanced HIV (CD4 count 12 x 106/l) invesfgated for pancytopenia Mycobacterium tuberculosis complex was cultured from bone marrow aspirate. Pipeline: GeneXpert PCR on aspirates to improve diagnosfc TAT

14 Newly diagnosed pafents with Burkips at GSH ARV rollout % cases HIV +ve

15 Burkips GSH : DiagnosFc categories 9% Burkip Lymphoma 9 % Burkip Leukaemia 32 % 50% Burkip Like Lymphoma Burkip Like Leukaemia BLL = B Cell lymphoma, unclassifiable with features intermediate between DLBCL and BL (WHO 2008) Aggressive lymphomas with morphological and genefc features of both DLBCL and BL Heterogenous category for cases not meefng criteria for classical BL or DLBCL

16 Hodgkin Lymphoma at GSH ARV rollout % of HL pafents HIV posifve 37% of HL cases have BM infiltrafon 17% of HL cases primary diagnosis on BM biopsy HIV - ve HIV +ve

17 BM Hodgkin lymphoma in an HIV pafent presenfng with pancytopenia and fever. H&E CD15 CD30 LMP-1

18 HIV Prevalence in Blood Donations (Western Province) First time donors Lapsed donors Repeat donors

19 Safety of our blood supply 6 confirmed cases No confirmed HIV transmission since NAT tesfng introduced in 2005 Blood donafon voluntary Donor quesfonnaire and screening

20 In Conclusion Laboratory challenges posed by HIV include Increasing volumes and spectrum of tests DiagnosFc challenges Semng of increasing socio- economic disparifes PotenFal solufons POC tesfng Teaching and training esp morphology for small labs GeneXpert for BM involvement by TB THANK YOU FOR YOUR ATTENTION!! References available on request