Bringing Innovative Diagnostics Close to Home
25 March 2013. Some of the most exciting innovations in diagnostics for HIV/AIDS and tuberculosis are being rolled out in Mozambique, a largely rural country where distance and lack of infrastructure have long impeded access to essential medicines. UNITAID is now investing in new technologies to bring rapid testing and monitoring closer to home.
Mozambique stretches 2,300 km along the Indian Ocean from South Africa to Tanzania. A civil war that ended in 1992 destroyed its health care system. Today the country has one of the lowest ratios of health care workers per population in all Africa and an HIV prevalence rate of over 11.5%.
Yet during a visit to the country last week, we witnessed how our investments in new diagnostic products can potentially revolutionize care for HIV/AIDS and tuberculosis.
UNITAID’s largest investment to date in Mozambique has been in HIV treatment for kids, through the Clinton Health Access Initiative (CHAI). As of 2012, almost 25,000 children are on kid-friendly HIV medicines thanks to UNITAID support. In 2005, only 3,000 children were on treatment. Above, we met children living with HIV from an orphanage in Mozambique’s capital Maputo, all on UNITAID-funded medicines.
One secret to this success: Better early infant diagnosis – the use of sophisticated technology to detect HIV in an infant’s blood. Using this technology, CHAI and UNITAID have been able to bring the number of infants tested for HIV in Mozambique from 5,892 in 2007 to 51,300 in 2012. As infants retain maternal antibodies that could result in a misleading diagnosis, the only way to test infants is with this specialized testing.
After all, proper diagnostics are the “gateway to treatment.” For children over 18 months and adults, a patient’s measure of immune system strength, known as the CD4 count, is vital to determine when patients need to start their HIV antiretroviral treatment. One challenge in Mozambique was the considerable loss to follow up of HIV-positive patients. Typically, blood samples were collected once a week and sent to nearby laboratories. For patients living in the outskirts of Maputo or in rural areas, the difficulty and cost of travel meant many never returned to get their result.
In 2010, CHAI started to pilot new diagnostic CD4 machines (above) with UNITAID funding. These machines can operate eight hours without electricity and produce rapid results, with a printout available on the spot.
According to Dr Ilesh Jani, Director of Mozambique's National Institute of Health, the introduction of these machines has seen a considerable decrease in patient loss. Pictured above at the Polana Canico centre in Maputo, Dr. Jani tells us that waiting time at this centre has dropped from one month to 20 minutes thanks to the new machines. Behind him, a nurse hands out CD4 count printouts.
By mid-2013, almost 100 sites will have access to these machines, known as “point-of-care” diagnostics – devices that can be used without extensive laboratory infrastructure and technical skills.
New point-of-care machines, also funded by UNITAID, are being evaluated now by Dr. Jani’s team. At Polana Canico, we saw a ground-breaking innovation: small, portable machines that can measure a patient’s viral load¸ which determines when a patient needs to switch to more powerful second-line antiretrovirals. The same machines can also conduct early infant diagnosis.
Until now, viral load and early infant diagnostic tests have been conducted in centralized laboratories by highly-trained crews. In Mozambique, blood spot tests needed to be transported many kilometres from where they are collected. The new machines we saw can provide results in one hour.
“This will be a game changer in treating children in Mozambique,” Luisa Brumana, Senior HIV/Specialist at UNICEF Mozambique tells us.
Thanks to these machines and the commitment of health workers, Mozambique is rapidly becoming one of the most advanced countries for point-of-care HIV technology. These technologies will be able to bring HIV-related care closer to communities and reduce visits to health facilities. UNITAID has committed up to US$ 140 million to CHAI, UNICEF and Médecins Sans Frontieres to scale up similar devices throughout remote regions in Africa.
At a meeting we held with civil society groups, we heard from HIV activist Angelo (picture above in yellow shirt), who comes from the northern city of Nampula. He told us that people living with HIV in his region are waiting impatiently for this point-of-care technology to reach rural areas. Today only the main city in his province has CD4 testing capacity.
Tuberculosis (TB) is another public health challenge for the country, with 50,000 cases diagnosed a year – probably half the actual number because of poor diagnostic capacity.
Above, patients wait for TB treatment outside Malvalane Hospital in Maputo, just meters from droves of people anxiously awaiting their test results. An airborne disease, TB thrives in close quarters and health care workers – already at a shortage in Mozambique – often are infected themselves. Over 50% of people living with HIV in Mozambique also have TB.
Until recently, spit samples were taken from patients and transferred to microscopy laboratories for TB testing. Depending on where the patients lived, results could take weeks. In rural Meconta province in northern Mozambique, we met lab technician Leonardo Nhanombe, who does TB and malaria microscopy testing. His small health centre – with only one doctor on staff – is only one out of three TB testing centres for an area of 180,000 people.
Better technology can make a difference. In 2012, UNITAID made a US$ 30 million investment to roll out a new automated rapid test, called GeneXpert, which can provide results in only two hours. UNITAID is introducing a GeneXpert machine into each of the 12 provinces of Mozambique and purchasing the cartridges needed for each test. We were able to visit a few machines (above) that have already been piloted in the country.
GeneXpert is especially important for combating the growing surge of deadly multi-drug resistant tuberculosis (MDR-TB), which is resistant to the drugs commonly used to treat TB. To test for MDR-TB, the bacilli that causes the disease needs to be grown in culture. This can take months. GeneXpert can do it in hours.
We also visited the only MDR-TB referral hospital in Maputo, an imposing six-story building in the midst of sweet potato fields on the outskirts of the city. The director of the hospital explained that patients sometimes wait three months for results and over 20% of her patients never return.
Once diagnosed with MDR-TB, patients must undergo a two-year course of toxic drugs.
At the referral hospital, masked patients wander like apparitions in between corridors in the MDR-TB ward, on the top floor of the building. Doctors rolled drug trolleys by, laden with the multiple toxic drugs and shots needed every day for MDR-TB treatment. The daily drug burden can easily surpass ten drugs and shots a day. Side effects include psychosis and deafness. The cure rate for these drugs is 50-60%. Better treatments are needed.
We met many remarkable health workers and patients during our trip during Mozambique – the challenges are immense but people are stepping up with inspiring resourcefulness and a dollop of new technology.
© Photo credit: Giulio Donini (except photos 8 and 12 by Ilan Moss).
Coming soon: Part 2 Mozambique: Better Malaria Diagnostics at the Community Level