Integrating Cryptococcal Screening
into HIV care: The Namibian story
Ministry of Health and Social Services
Namibia
Francina Tjituka: Chief Health Program Officer
National HIV/AIDS, Hepatitis and STI Control Program
Presented to the AIDS 2016 Conference
Presentation Outline
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Background
Cryptococcus sero-prevalence in Namibia
Highlights of Namibia 2014 ART Guidelines
Current Cryptococcal Screening Practices
Summary
Questions and Discussion
Unit 11: Slide 2
Background
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Namibia Population 2.2m
Adult HIV prevalence 14%
Estimated 230 000 PLHIV
About 12% of patients initiating ART in Namibia
have CD4 count < 100 cells/µL
Results of the 2014 Laboratory-based Crypto
Prevalence Study among PLHIV in Namibia
 CrAg prevalence 3.3% overall
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3.9% for CD4+ counts of CD4+<100 cells/µL
2.3% for CD4+ counts of 100-200 cells/µL
Unit 11: Slide 3
Namibia: High-Prevalence Regions
CrAg Prevalence per Region, June 2014-May 2015
Source. Meditech: NIP Crypto Screening Program Data (2015)
Unit 11: Slide 4
2014 Namibia ART
Guidelines (1)
2014 Namibia ART
Guidelines (2)
Laboratory Infrastructure
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40 laboratories operated by the National Institute
of Pathology (NIP)
28/40 labs provide CD4 testing services.
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9/28 labs use flow cytometry to conduct CD4 testing
19 have very low volume and use PIMA machines to conduct
CD4 testing.
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~15 labs started conducting reflexive laboratorybased screening for all samples with CD4<100
cells/µL in June 2014.
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60-70% of all CD4 counts done in the country are being done in the 15 labs that are
conducting CrAg screening,
We estimate that 60-70% of patients with CD4<100 cells/µL have access to CrAg
screening.
Unit 11: Slide 7
Current Namibia Institute of
Pathology (NIP) Laboratory
Reflex Screening
then
+
STEP 1
Blood
collected at
initial patients
visit
or
STEP 2
STEP 3
CD4 + CrAg
testing on
samples
with
CD4<100
Treatment
decisions
taken at first
follow-up
visit
CrAg Screening in Namibia Currently
Susceptible population:
• ART initiators with CD<100
• ART defaulters with CD4<100
Access to CrAg
reflexive
screening:
~70%
Able to
access
CrAg
screening
through
clinicianinitiated
request for
CrAg
screening
Assessment of laboratory-based
CD4 sites
Observations:
• Every eligible sample received is screened for CrAg
• Lab results posted to Laboratory Information System (MEDITECH) within 24
hours
Laboratory-based
Challenges:
• Little control over whether results are received and used by sites
Assessment of sites using PIMA
CD4
Observations:
• Most providers aware of CrAg screening, but do not
always remember to send samples for CrAg after seeing a
PIMA CD4<100
PIMA at
Point of Care
• Results posted within 24hrs of samples being sent for
CrAg, but facility staff often do not review CrAg result
until next patient visit
• Equipment failure may delay results (SMS printers,
MEDITECH portals)
• Facilities without doctors on staff do not have access to
fluconazole to begin treatment
Availability of fluconazole and other
antifungals
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Fluconazole was available in the country through the
Diflucan Partnership Program until approximately 2013
Since 2013 MoHSS has been purchasing generic
fluconazole
Fluconazole is part of the Namibian Essential Medicines
(NEMs) list
 Currently classified as an “AB” drug,
 Means that it can only be prescribed by a medical officer
or a specialist
Amphotericin B is available in hospitals
5-Fluorocytosine (5-FC) is not on the essential
medicines list and is not available in the country.
Unit 11: Slide 12
Summary
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Namibia has successfully integrated
Creptococcal screening into HIV care
 Recommendations included in the national
guidelines in January 2014
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The biggest NIP laboratories initiated reflexive
CrAg screening on all CD4 specimens <100
cells/mm3 in June 2014.
An estimated 70% of patients with CD4<100
cells/mm3 have access to CrAg testing through
the NIP Lab-based reflexive program.
Unit 11: Slide 13
Acknowledgements
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Ministry of Health and Social Services (MoHSS)
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Namibia Institute of Pathology (NIP)
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President’s Emergency Plan for AIDS Relief (PEPFAR).
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Centers for Disease Control and Prevention (CDC)
 CDC Namibia Office
 CDC Atlanta: Mycotic Division
Unit 11: Slide 14
THANK YOU
Unit 11: Slide 15