CROI 2018 Abstract eBook

Abstract eBook

Poster Abstracts

being estimated at 23.5% in women and 31.5% in men. The 2010 national South African HIV testing guidelines mandates the universal offer of testing in all healthcare facilities. Studies have reported that delivery of HIV Testing Services (HTS) struggle due to the requirement of extensive pre-and post-test counselling and a lack of standardized training/supervision. Methods: A multi-prong approach was use to evaluate the current implementation of HTS in ten primary health care facilities in South Africa (Figure 1). First we conducted patient exit interviews to quantify engagement in HTS services. Second we systematically mapped the flow of individual patients through the clinic. Finally, we audited the clinic documentation of newly diagnosed HIV positive individuals to quantify antiretroviral treatment (ART) initiation. Results: Of those interviewed 1548 (51.8%) patients reported that they had not received a HIV test in the last 12 months. Overall testing acceptance was high at 84.7% (244) but less then 10% (288) of the patients were offered testing. Female patients were significantly more likely to be offered testing (233, 11.9% vs. 55, 5.8% in males), even though testing acceptance was equal in both sexes (41, 74.6% vs. 203, 87.1%). Value streammapping revealed that patients undergoing HTS had longer total visit times (160 minutes; IQR 135, 249) compared to those without HTS (119 minutes; IQR 81,197). Patients were usually offered HTS an average of 56 minutes into their care (IQR 27, 82). Accounting for age and gender, patients offered HIV testing had a total visit time of 51 minutes (95% CI: 30-72) more compared to those not offered testing. Of those testing HIV positive, 571 patients (58.8%) had ART initiation documented by 90s days of testing positive, despite a universal test and treat policy. Conclusion: Despite a national mandate less than 10% of patients were offered HTS in the clinic setting, this represents a missed opportunity especially given that testing acceptance was high. The poor delivery of HTS appears to be due to a failure to recommend HTS and the added time burden placed on those accepting testing. Health system, rather than patient factors need to be addressed to improve HTS delivery. 988 HIGH PERCENTAGE OF UNDIAGNOSED HIV CASES IN A HYPER-ENDEMIC SOUTH AFRICAN POPULATION Alain Vandormael 1 , Tulio de Oliveira 1 , Frank Tanser 1 , Till Bärnighausen 2 , Joshua T. Herbeck 3 1 University of KwaZulu-Natal, Durban, South Africa, 2 Heidelberg University, Heidelberg, Germany, 3 University of Washington, Seattle, WA, USA Background: Undiagnosed HIV infections could undermine efforts to reverse the global AIDS epidemic by 2030. In this study, we estimated the percentage of HIV-positive persons who remain undiagnosed within a hyper-endemic South African community. Methods: The data comes from a population-based surveillance system located in the Umkhanyakude district of the northern KwaZulu-Natal province, South Africa. We annually tested 38,661 adults for HIV between 2005 and 2016. Using the HIV-positive test results of 12,039 (31%) participants, we then back- calculated the incidence of infection and derived the number of undiagnosed cases from this result. Results: The percentage of undiagnosed HIV cases decreased from 29.3% in 2005 to 15.8% in 2011. During this period, however, approximately 50% of the participants refused to test for HIV, which lengthened the average time from infection to diagnosis. Consequently, the percentage of undiagnosed HIV cases reversed direction and steadily increased from 16.1% to 18.9% over the 2012 to 2016 period. Conclusion: Results from this hyper-endemic South African setting show that the HIV testing rate is low, with long infection times, and an unsatisfactorily high percentage of undiagnosed cases. A high level of repeat HIV testing is

needed to minimize the time from infection to diagnosis if the global AIDS epidemic is to be reversed within the next two decades.

989 REDUCING TIME FOR HIV VIRAL LOAD RESULT DELIVERY TO ART FACILITIES IN MALAWI Natasha Gous 1 , Frank Chirwa 1 , Jeff Takle 1 , Alan Schooley 2

Poster Abstracts

1 SystemOne, Boston, MA, USA, 2 University of California Los Angeles, Los Angeles, CA, USA Background: HIV viral load (VL) testing is the preferred method for antiretroviral treatment (ART) monitoring in Malawi. Specimens are collected from~650 facilities, tested at central laboratories and paper-based results are returned by courier to facilities. This results in long turnaround times (TAT) in result receipt (42-90days), delaying and often negating their use for clinical decision-making. Loss of results also occurs; CHAI estimates that only 50% of HIVVL results are returned to referring facilities in Malawi. A solar-powered result terminal was developed to improve the efficiency and TAT of result delivery from centralized laboratories to remote facilities. The terminal is being piloted in Malawi to assess impact. Methods: Result terminal: Aspect ReporterTM(SystemOne) consists of a.) A small, solar-powered server which receives results over cellular network from HIVVL instruments located centrally; b.) An inexpensive tablet located in the facility displays results on a simple interface. Pilot: Two reference laboratories performing Abbott VL testing were connected to Aspect network. Aspect Reporters were implemented in 12 ART facilities. Analysis: Data from a subset of four ART facilities was collected to compare reliability (% loss of results) and time to result receipt (from test completion to result receipt at facility), pre- and post-installation of Aspect Reporter. Results: Pre-Aspect: Time points for 79 specimens were collected. Mean time for delivery of paper results from the laboratory to the clinic was 13.5days (SD=10.5). Post-Aspect: Time points for 131 specimens were collected. Mean time for delivery of digital VL results from the laboratory to Aspect server was 0.5days (SD=0.3). For the pilot, an ‘artificial’, manual approval step was introduced on the server as a check. Mean time to delivery from the server to Aspect Reporter (n=117) was 6.2days (SD=5.9) due to approval. Thus, total mean time to digital result delivery from laboratory to clinic was 6.7days (SD=5.9); 50% reduction compared to paper delivery. Going forward, removal of the ‘artificial’ approval step will result in a 96% reduction in TAT (0.5days vs 13.5days). Reliability: 10.7% (n=14) results not approved for delivery. Conclusion: Aspect Reporter improves the time and reliability of result availability at facilities, improving the laboratory-clinical interface and allowing earlier patient management. Aspect Reporter has application for rapid reporting of other laboratory-based results to remote clinics.

CROI 2018 378