 Right, so can I just look around other questions? So let's see one two three four five six, right? We have seven questions. I can see I will start actually kept starting on this side So I'm going to this time around start on this side. Yes I'm Isaac from the access campaign and I'm also from Zimbabwe. So my question is about the presentation on the 1990 Assessment that you did It's impressive. I'm more being Zimbabwe. It's impressive that the national HIV program is doing this well I wanted to ask about the differences between the MSF supported projects What is it that MSF is doing differently that you would recommend to the national program to improve in their project to get to the Same level as MSF Thank you. I'll check a few more questions before you respond Right, so you speak into that side of the room was it yep that person go ahead. Hi, Cathy QS and to be advised as for my Question is to Jay Jay, thanks very much for that presentation that Show the results of that study that that really influenced the change in WHO guidelines So I'd like to know what you think about the risks of implementing the short regimen in Eastern Europe in your study I think less than 30% of people were eligible. They were quite strict inclusion guidelines And also you're quite strict in the follow-up and you had quite a big percentage of patients who were failures What do you think the risk is of implementing that in programmatic conditions where perhaps the That excitement of a shorter cheaper regimen might be overwhelmed the inclusion and follow-up criteria Thank you. I'll take two more and then we'll get responses. Yes, right like that. Go ahead Yes, the person with the mic Hi I'm Janet. I was in with the MSF friends. This question's for Allison the study on adolescents. I wondered if through the different discussions You had about the clinical care and adherence if there were any discussions of the adolescents Sexuality especially since the family environment seemed like it had Sigma associated with it and What the MSF counseling program did to address that since I guess adolescence is a time of emerging sexuality for HIV positive adolescents Thank you One more. Yes, the person can you pass it on to the person in front of you and then Hi, we'll get answers and then come back MSF My question is also for Allison. You mentioned that you were revising the model of care currently for the adolescent HIV program, I wondered if you could talk about what those revised Implementation models might include Because it's a it's really fascinating and really really important to support adolescents to better adhere and if if if you're intending to share some of those ideas with other MSF projects across the movement Can we have a microphone up here in front You've got one. Okay So we have two questions online one from the field which is to Jay Asking how do we plan to proceed with extending short regimen and DRTB regimes throughout other MSF national TV programs that we have to support Additionally, some countries cite high levels of resistance to canomysine and Pro-thionomide as a reason for not implementing the short regimen How can we convince them that shorter regimens would still work? And then the second question is from an epidemiologist, so I hope that you'll be able to make this Understandable for both epi's and non epi's in the audience Did you include patients lost to follow-up in your analysis? If yes, did you perform a sensitivity analysis by excluding them and seeing what the difference would be? For treatment groups on unsuccessful outcomes We can expect more loss to follow-up patients in the standard 24 months regime as Compared to the nine months regime and through a higher rate of death plus failure in the short course as compared to the standard regimen Did you look at that? That's a tough question today Right, so apologies. I'd suggest we take some responses Please keep your answers succinct so that we can take more questions We still have about 15 minutes of discussion time. So I'll start with the 1990 90 question Okay, so thank you for the question unfortunately, I Can have an answer but I think I'm not the more appropriate person to answer to that and I don't know if I can Let the power of somebody who is here who know better the sitting than me and to answer this question if it's possible There is Ellen with here and if she doesn't mind to answer for me I think she will be a more adequate of the room. Thank you, Ellen Thanks, Lauren. Thanks for presenting it. It's really exciting I just want to say a big thank to both the field teams there because they've been working so hard in those projects and regarding testing One of the things in gootoo. They've been doing for the last two three years is night testing. So going out Once a week to a kind of hot spots in terms of attracting men Although we still see lower rates of testing in men and I'd say MSF to support in more campaigns in gootoo than probably You know other national settings in terms of ART I think what's different is the differentiated models of care that are going on in gootoo in terms of keeping people in treatment So the community ART clubs fast track and so on what I think is interesting is we don't see better virological suppression Despite we think we're investing a lot in Counseling and have made sure that primary counselors are in most clinics and are trained and so on So I think that is quite interesting that really we're not seeing that impact on the virological suppression But I think Zimbabwe is is doing amazingly overall and they're also looking We have shared those experiences and looking to adopt that and some of those experiences at national level Thank you very much for that. So we have three questions for you Jay. Yeah, can you start? Yeah, so Maybe first I'll start with Kathy's question in the room Risks of the short course regimen Agree, so I think this was the background to to doing the study in Uzbekistan The the regimen that was described in Bangladesh was spectacularly successful It was a single arm observational study, but 90 percent Relapse free after one year was something new. I think for MDR TB We'd been having 50 to 60 percent success rates so I think everyone was overjoyed at that result and We felt that there was a gap in the knowledge in a country which had high rates of second-line drug resistance So that that group of patients as you know Had worse outcomes in the Balgadesh cohort So we wanted to see what effect we could find in Uzbekistan I think there are challenges and and I think when we do eventually get to kind of presenting our full data that there are some Failures in our in our study and the question is how do you manage those failures? So it MSF we've got this policy that we're pushing for access to the newer TB drugs And so we're managing those patients with those newer TB drugs and putting them on longer treatments Do I think it's the short course regimen has a role in the former Soviet Union and Eastern Europe? Policy at the moment suggests yes There's still obviously lots of questions about which patients would qualify exact inclusion criteria where the first-line drug resistance Would exclude patients? In our study we included people with first-line drug resistance So it found be told in parasyne amide resistance, but excluded patients with suspected or Confirmed second-line drug resistance So yeah, I think there are risks No, no one really knows And unfortunately that the randomized clinical trial does not recruit from countries with very high rates of second-line drug resistance And the last question lost the follow-up There's a second question about lost the follow-up. It's a second question about MSF pushing access to the short course regimen in collaborative programs. So To some degree, I think the answer is yes So for example in in Swaziland where another study was done using the short course regimen in high HIV prevalent setting MSF is collaborating with the Ministry of Health to roll out the short regimen. I believe nationally In Uzbekistan, we're starting to roll out the short regimen in the areas that we're working Further than that, I believe that MSF is also Conducting a study looking at the short regimen using one of the newer drugs And we're obviously fielding lots of questions from national TV programs around the uncertainties of very specific drug resistance And then the last one about the epidemiologists. Yeah, okay, so So this comes down to the second analysis that we did looking at end-of-treatment outcomes And it it's a yeah I guess it's a little bit confusing because on the one hand We looked at end-of-treatment from a 20 month regimen and tried to compare it to end-of-treatment from a nine month regimen So that the patients in the nine month group When they finish treatment, they're no longer as engaged in healthcare as the people still receiving daily treatment So the loss to follow-up rates. Yes, we did include them in the study We took quite a conservative approach to loss to follow-up in the sense that in the original protocol We we looked at microbiological results from end of end of one year follow-up Which is quite difficult and At the moment that our project team is still trying to find some patients who have moved abroad for work who who have moved out of The region to see if we can get any kind of clinical follow-up after a year of finishing treatment Sensitivity analysis. Yes, we will be doing that And also, I think Mattia's impression is that the short regimen will lead to lower rates of loss to follow-up You intuitively you think that's going to be correct, but also the patients get better quicker And treatments are not explained well enough Then you might find that people actually suddenly feel better and go back to work and a loss to follow-up from your program So it's also the pattern of loss to follow-up is something we're looking into. Thank you So I'll send if you can respond briefly to those two questions Participants in the study I think it's clear from Sexual health services that were available on specifically time Perhaps a need for more support in that area. So sexuality was beyond the scope Something that was perhaps relevant to a very small proportion of those In terms of the revised Program activities Desk and the team in the field are very much working on right now Designing that new program and drawing very much on the findings from the qualitative research We know and they're going to be Circulating and sharing that document. I'm sure internally and through MSF networks We know that that Excuse me the focus of those revised activities will be a great focus for example on peer groups Which were very much lacking in this this particular setting before Far more interventions at the family level trying to support households, especially Caregivers as well as the adolescents themselves More focus on good quality adherence counseling more advocacy for a counseling cadre and more support to counselors as Adolescents go through the disclosure process Those are the main components that we expect to see in that revised model of care. Thank you So we have another five six minutes. I'll take a limited number of questions But let me just do a count of how many so there's one holding the microphone and they're two more in the middle of the room Great. So stick to those and then get responses. Go ahead, please. Okay. Thank you all for excellent presentations My name is Minna Smith clinical epidemiologist based at the Kenya Medical Research Institute My question is directed to Matthew and Jay Excellent studies. I understand that you potentially took a more practical implementation Perspective in your research But I was wondering whether you also considered using a randomized design that might have Removed some of the limitations and help the policy change process. Thank you for that. Let's go to the next one Thank you, it's Bev Stringer again, and it's a question for Allison and I was struck similarity with results of an adherence study done in Uzbekistan and Chona Horta's probably in the room She published that study and in particular it was two results that you had which was linked to control aspects of the treatment approach Where in this particular case, you know the lack of autonomy that patients felt impacted on Their levels of adherence, but also the dialogue, you know having dialogue ongoing Improving dialogue with the health worker was another aspect and I wonder if through your lit reviews another Knowledge you have about adherence strategies, whether you are seeing Similar results across, you know diseases that require adherence, you know chronic disease And whether you think then there's a broader impact that could be had where qualitative research is Influencing adherence strategies more broadly And the last one Yeah, I've a question for Jay a hundred thousand questions. Can you introduce yourself, please? My name is Yostan Amir. I'm MSF Holland board member. I'm also evaluating the Guto project For OCB and I have a question for Allison Jay, thanks for your interesting presentation. I've also worked in Uzbekistan before by the way But that's a long time ago Did you look at in your study also to the patient experience in terms of side effects, etc. And if so, could you say something about that? And Maybe also, but that was probably not the objective of your study about more qualitative patient experience in terms of patient satisfaction For now when still on this issue of the third 19 not differing between Guto and the rest of the country I'm really sorry, but if you ask three questions, we would get time for any answers despite this despite the fact that there are Real community adherence models in Guto, which are also in the country, but more intense in the in the project Can you reflect a bit on what then the difference what why the difference might occur? Yeah, thank you very much. I'm really sorry, but we are running out of time Great, so should we start with Allison? These are Settings at least in relation to HIV whether it's adolescence or children, so it's not lessons And it's not specific to this Very very typical. I think there probably are lessons that can be drawn for Other diseases as well particularly TB in the work that Shona did it definitely speaks to those findings I'm sure TB adherence in many other settings Outside Africa whether it also speaks to the same dialogues in relation to other illnesses I'm I'm less familiar with that literature I I wouldn't be surprised and I think it would be something that we could perhaps be looking at elsewhere in terms of the dialogues that Patients are having with health workers and in relation to other diseases. Yeah Really sorry Allison, but as a TV epidemiologist, I must interject here Do we have data to show that where we have a more relaxed and Greater autonomy that we actually achieve greater adherence I think some of the practices you showed are outright wrong But the opposite of that is if we let people do as the adolescence do as they please would they take their pills Is that we have to allow people to have frank and honest discussions that they don't feel they have to hide and be ashamed and forced into some silence So when they can't take their pills for whatever reason we know the multitude of barriers when those when they face those barriers Instead of hiding from it that they can address them and speak frankly and find solutions to them. Sure. Thank you Shall we carry on? Yeah Okay, thanks for the questions. I'll keep the answers short because we're running out of time But so did we collect side effect data? Yes Absolutely, we collect it in a structured way that the comparison will be more difficult because in regular programs We don't collect kind of we don't grade side effect Information as much as we would in a study Qualitative study. Yeah, we've got a proposal for that. It's on the cards Most of the patients that were involved in this in the prospective aspect of this study Are still in the region and we still engage with them through the program so I think I think that that's one method of Convincing is the wrong word, but convinced. Yeah convincing programs to suggest that a shorter regimen is Beneficial for patients and kind of their lives Just add that there are a range of RCTs going on for this exact question and the stream trial would be reporting Hopefully very soon on on the Bangladesh your regimen Martin. Do you have anything to add? I just wanted to add I think for the study in in Maputo about PLD, I don't think there's a need to do a randomized interventional study I don't think there's actually many scientific questions about the use of PLD for Kaposi's It's standard of care and has been for decades in developed countries It's just when you take a little vial that costs three hundred and fifty dollars and you need two to three vials per round It's a cost question so MSF Negotiated hard and got a lower price per vial and now we're you know It's hoping to get better access with generic products and cheaper prices to bring it up So the the purpose of what we were doing is really as a stepping stone for advocacy and documentation show what can be done I don't think there's a scientific question necessarily needs to be answered. Thank you very much for that So unfortunately would run out of time We probably would have enough questions to go for the rest of the day in this very exciting session I'm not going to take the time to summarize each presentation because we've run out of time But please feel free to catch the speaker during the coffee break and ask your questions. Thank you very much