Thursday, April 28, 2016

Countries have scaled up viral load testing but health workers have failed to interpret the results ( I first published this in this publication, below is the unedited version)

Health workers still do not know how to use and to communicate high viral load results and neither do patients understand the terms

By Esther Nakkazi

Viral load testing may be the gold standard for monitoring HIV treatment outcomes but countries that have scaled it up have an emerging problem; some health workers cannot interpret the laboratory results to appropriately manage patients on anti HIV drugs.

Laboratory reports with viral load results now have to be issued with a sad face or a smiling face to help health workers and patients interpret the outcomes.

Kenneth Mwehonge, the health policy programs officer at the Coalition for Health Promotion and Social Development (HEPS Uganda) says there is low level of knowledge of viral load among people with HIV and health workers.

“Interpretation of results is still a challenge. Health workers still do not know how to use them to communicate the high viral load and neither do patients understand the terms,” he says.

The confusion is especially evident because both parties are used to CD4 count, which has been well communicated over the years. 

Experts have termed CD4 as ‘soldiers’ that protect them or improve their immunity but there is no equivalent for viral load yet in the local dialect.

CD4 cells are a type of white blood cells that play a major role in protecting the body from infection. They send signals to activate the body’s immune response when they detect intruders like bacteria. The higher the CD4 count the better for a patient.

“Patients ask after their immunity in terms of ‘soldiers’ (CD4) increasing and reducing,” said Carol Nakintu, a nurse at Kyosima clinic in a suburb of the capital, Kampala, that offers HIV care to patients in Kampala.

Over the years, patients have been told to know that the higher the CD4 count the healthier and loosely they have many ‘soldiers’ keeping them safe. It is the opposite for viral load because the lower the viral load the healthier.

Health workers say unlike CD4 count where HIV positive patients will know how many ‘soldiers’ are keeping guard, if they communicate viral load saying it is undetectable they will think that they are cured and do not need to take their drugs says Mwehonge.

In July 2013, the WHO passed HIV treatment guidelines  to monitor HIV patients response to anti retroviral drugs and diagnosis of treatment failure.

The guidelines recommend routine viral load testing six months after initiating treatment and once a year thereafter.

In Uganda, viral load testing was taken up by most of the HIV treatment facilities only a year back and health workers say they did not think the demand would be high because everybody was using CD4 and they were comfortable with interpreting the results.

The viral load test measures the amount of HIV virus in the blood, showing if a patient is responding to treatment. If the virus is above 1000 copies/ml its high and detectable if it lower than 1000 copies/ml then its low or undetectable and there is virologic suppression. 

Sad and Smiling face for Viral load results;

High viral load results show two things; either the patient is not taking their drugs diligently thus not adhering or there is drug resistance. They can at this point transmit HIV to a sexual partner. The laboratory results issued to such a patients report have a sad face.

While a low viral load means the virus is not affecting the health of the patient, they are less infectious and will not spread it to their sexual partner. The laboratory results have a sad face.

At the Uganda Ministry of Health Central Public Health Laboratories where about 600,000 samples of viral load are analysed annually, Charles Kiyaga, the national program coordinator says besides the gloomy and smiling faces on the patients’ reports they also provide footnotes and mentorship to health workers to be able to interpret the results.

When the lab report has a gloomy face, they also encourage the patient to get adherence support before they declare treatment failure and switching to second line HIV medicines that are more expensive.

In 2015, Central Public Health Laboratories of the 10,113 patients eligible for a second viral load test, only 66 percent of patients with a detectable viral load received their results for the second test.

This is informing us that the data is not utilised for patient management or some health facilities have no capacity to follow up patients, said Kiyaga. The viral load test costs about $20 and CPHL makes it available to all HIV patients in Uganda.

The Médecins Sans Frontières (MSF) laboratory in Arua, in North Western Uganda, by January 2016, the lab was serving 16,000 patients and of these 17-21 percent had a detectable viral load.

Ephraim Ajule, viral load activity manager, at the MSF lab says they advise the patients with a detectable viral load to undergo adherence counselling.

“When it comes to adherence it is the counsellors who know what to say and what to do,” says Ajule. But many health facilities including theirs have few or no counsellors to do adherence counselling. It is done by nurses.

Testing is repeated annually for patients with undetectable viral load and every six months if the patient is on second line drugs and for children. The science is that after the first year of initiating treatment patients viral load is usually undetectable. 

But children are checked often because they do not swallow their drugs diligently and appropriate dosage should be by weight which is usually not measured.  “Children can refuse to take drugs and they do not understand why they should take these drugs, as well when they become teenagers they go into denial,” said nurse Nakintu.

If adherence counselling is done properly and the viral load is measured and its still high then there is drug failure and the patient has to be switched. But nurses are afraid to switch patients to second or third line HIV drugs which do not exit.

In Uganda, access to third line drugs is very limited and most of these are still not in public health facilities observed Mwehonge.

“I am scared to put patients on second or third line drugs. I am not going to change the life of this person. I want to keep them on first line because I do not know what else to give them,” said Nakintu.

“We sometimes have to create individualised regimens for patients who fail on first line drugs which is a problem. Some of these drugs are not in the country and have to be ordered from another country. From the time it is confirmed to be resistant to the time they are initiated it takes 10 months,” said Ajule.

This problem is not unique to Uganda. In rural South Africa more than half of the patients with persistent viremia are not switched to second line, and for those who are switched it happens with a delay of one year from an elevated viral load (Venables at al. 20th IAS Conference)

In the Swaziland viral monitoring program of the patients with detectable viral load, after 6 months only 5% were switched to second line, 51% were still on first line, 37% were lost to follow up, 9% had died (Jobanputra JAIDS 2014)

To solve the problem of viral load issues, experts suggest that more adherence counsellors should be trained, better monitoring and follow up should be done as well more advocacy is required.

Ultimately, everyone agrees that patient empowerment about viral load is key and campaigns to educate all stakeholders should start. Some centres of excellence like Infectious Disease Institute (IDI) in Kampala have already done it.

Patients have to ask physicians about their viral load which may be difficult at the beginning but it will be done. It needs to come down to the clients themselves, said Isaac Ssewanyana, the director at the Ministry of Health, Central Public Health Laboratories (CPHL)

Ssewanyana suggests that a guide on how to make a decision by health workers should be developed.
“The approach of empowering patients and educating them is what will change the scenario. Patients should have the anger to demand for their viral load results just as they ask after their CD4 count,” said Charles Brown an HIV prevention advocate with IDI.


Tuesday, April 26, 2016

Project saves lives; reduces malaria prevalence to single digits

A student walks away after receiving a bed net from Malaria Consortium

By Esther Nakkazi

Last year, I travelled with a team from Malaria Consortium Uganda to Tororo district. The week long exercise was to distribute long-lasting insecticide-treated bednets to school going children.

Through the  Malaria Control Culture Project  funded by Comic Relief and the 2013 government national mass distribution campaign, Malaria prevalence has gone down in Tororo from 53% in 2009 to 33% in 2014 and 18% in 2015 and only 8% this year.

Our first stop was at Atapara Primary School, Paya sub-county, a government-aided school with most of the children from poor households and under the government Universal Primary Education (UPE).

When we entered the primary one class, I was shocked at the numbers of pupils, some sited on the floor and others sharing desks. I wondered how the children, most of them without shoes, nor school uniform would even use the bednets. This class had 249 pupils. 

At break time, the whole school assembled under a huge tree, we were introduced, visitors from Malaria Consortium who had come to bring bednets. You could see the excitement among pupils. Parents started trekking into the school and joined us under the huge tree in the school compound.

Before the Malaria Consortium big van with bednets arrived, we had an awareness session. The deputy headmaster, Stephen Oketcho told us that about 15 percent out of a student population of 1,209 suffer from malaria per week. That increases school absenteeism and of course affects students performance.

Students walk home with bed nets after school

The stats are also representative of Tororo district, which has one of the highest malaria cases in the world. People who live in Tororo have annual mosquito bites of 560 times or 1.5 bites per night according to a study by Malaria Consortium.

Tororo, located in eastern Uganda near the border with Kenya has a weather pattern that favours mosquito breeding. It rains often, leaving soggy soils. So does the flat terrain, with rocky grounds that collect stagnant water. With this the most viable option could be sleeping in mosquito nets but it takes  time for a behaviour to catch up.

The awareness exercise kicked off. 'How many of you slept under a mosquito net yesterday'? Claire Nyachwo, a health educator shouted in the local Japadhola language. Some hands shot up, roughly half of the school pupils and many parents mostly the women.

Prior to this project, in 2013, the Uganda government had carried out a national universal coverage campaign distributing free bed nets to all its citizens.

Dr. Godfrey Magumba, the head of Malaria Consortium Uganda said they built on that mass campaign to distribute bednets to pregnant women attending antenatal care, to school going children in primary schools and to business people in the private sector.

Through the Malaria Control Culture project in Tororo headed by Dr. Julian Atim they aimed to increase the proportion of household members who slept under insecticide treated bednets and schools are a sure way to build that critical mass from the community.

Dr. Anthony Nuwa, the Malaria Consortium Uganda country technical coordinator explained that schools are key to maintain a coverage of 80 percent of people sleeping under insecticide treated nets.
Within two years of working in Tororo , bednet coverage has remained high at 91 percent against the national level of 90 percent in 2014 and 70 percent in 2015.

In most cases, after national mass distribution bednet coverage falls by 20 percent in the first year and up to 60 percent in 2 years without replacement but Tororo district has maintained its high coverage because of the project intervention, explained Dr. Nuwa.

Back at Atapara primary school, Nyachwo went on to explain to the eager listeners, why sleeping under an insecticide-treated bed net was important. She asked teachers how they know that a child has malaria?

“Once a kid is shivering, has a high temperature, has flu or vomits, we suspect malaria. We escort them back home and advise that they go to a hospital and test for malaria,” said teacher Abbo. The school has no school nurse.

“How long does it take for the chemicals to expire from bednets when washed? How often should bednets be washed? some parents asked.

Dr. Magumba says bednets can be washed with bar soap not a detergent and they should be dried under a shade so that the chemical in the bednet is maintained.

When the awareness exercise was over other pupils were told to return to their classes except pupils from three classes, primary one, three and five who were to receive bed nets.

So last week the   Malaria Control Culture Project won the Africa Excellence Awards ‘Change Communication’ category. Daudi Ochieng, Malaria Consortium Uganda Communications Manager said that this campaign approach can inspire other public health campaigns to engage the private sector and stimulate the individual responsibility for health seeking behaviour to create sustainable gain in behaviour change.

The award honours outstanding achievements and the most successful campaigns and projects in the field of public relations and communications in Africa.

The project focused on two communication objectives; to create a culture of sleeping under an insecticide-treated bednet every night and to promote other malaria control behaviour, such as seeking treatment within 24 hours of fever onset and testing before treatment.

On World Malaria day, celebrated 25 April World over, during a press conference at their offices Dr. Atim said more people in Tororo are aware of the importance of bednets and are willing to buy and replace an old one, which improves sustainability of the project.

Dr. Nuwa said the major ingredient of this project was change communication that was done effectively.

It is now the onus of the government to adopt this innovation so that school going children are given bednets and effective communication is done. But also that they do not just get free things but learn to buy and replace old ones before the government gives free ones.

For in this project after the bednets, which last for 2-3 years became old, people bought and replaced them after knowing their importance.

“We hope this reinforces the fact that when you do little efforts and it makes a difference it can save people’s lives,” concluded Magumba.  


Monday, April 18, 2016

10 'Interesting' questions About the Dapivirine Vaginal Ring:

By Esther Nakkazi

On 22 February this year, news of two trials of HIV prevention for women was released at the 2016 CROIC Conference. A big thank you to the researchers and the 2,629 women at 15 sites in Malawi, South Africa, Uganda and Zimbabwe who enrolled in the ASPIRE study led by the Microbicide Trials Network

Another big thanks to the 1,959 women at 7 sites in South Africa and Uganda who participated in the Ring Study, led by the International Partnership for Microbicides and of course the scientists. They added another tool for HIV prevention that can be used by women.

In both studies, the ASPIRE and The Ring Study some women used the ring with dapivirine, a first long-acting ARV-based product while others used a placebo. These were Phase III trials designed to evaluate whether the dapivirine ring is safe and effective when used for one month at a time. Both studies found evidence of modest protection.

Women over 21 years of age appeared also to use the ring most consistently. The ring was not effective in women ages 18 to 21 years, who also had the lowest adherence.

Since they released news about these studies, I have attended many forums discussing the vaginal ring results, worth mentioning is our own science cafe organised by the Health Journalists Network in Uganda. It was the 11th we ever held and generated the biggest media coverage and buzz.

For the forums I have attended pertaining to this new innovation here are some of damn absurd questions that I have heard being posed to scientists:

  1. Can’t the vaginal ring get stuck in the fallopian tubes?
  2. Will the ring be a ‘one size fits all’? (The concern was that some penises are bigger than others and will not pass through the ring?)
  3. Will the dosage in the ring be effective for people who have multiple sex acts? Won’t the dapivirine reduce and not last for the one month it is intended for?
  4. If you wash the vagina frequently won’t it affect the medicine (dapivirine) in the ring? 
  5. Does douching affect the ring? 
  6. How long does the ring start working after inserting it?
  7. Won’t the vaginal ring get stuck on the penis during sex?
  8. Doesn't the dapivirine vaginal ring make women infertile?
  9. Can the ring be used by lesbians?
  10. For the ring not to work among below 21 year olds is it only because of adherence or for another reason like the age of the vagina?