Impact of the implementation of new guidelines on the management of patients with HIV infection at an advanced HIV clinic in Kinshasa, Democratic Republic of Congo (DRC).

BACKGROUND: HIV continues to be the main determinant morbidity with high mortality rates in Sub-Saharan Africa, with a high number of patients being late presenters with advanced HIV. Clinical management of advanced HIV patients is thus complex and requires strict adherence to updated, empirical and simplified guidelines. The current study investigated the impact of the implementation of a new clinical guideline on the management of advanced HIV in Kinshasa, Democratic Republic of Congo (DRC). METHODS: A retrospective analysis of routine clinical data of advanced HIV patients was conducted for the periods; February 2016 to March 2017, before implementation of new guidelines, and November 2017 to July 2018, after the implementation of new guidelines. Eligible patients were patients with CD4 < 200 cell/µl and presenting with at least 1 of 4 opportunistic infections. Patient files were reviewed by a medical doctor and a committee of 3 other doctors for congruence. Statistical significance was set at 0.05%. RESULTS: Two hundred four and Two hundred thirty-one patients were eligible for inclusion before and after the implementation of new guidelines respectively. Sex and age distributions were similar for both periods, and median CD4 were 36 & 52 cell/µl, before and after the new guidelines implementation, respectively. 40.7% of patients had at least 1 missed/incorrect diagnosis before the new guidelines compared to 30% after new guidelines, p < 0.05. Clinical diagnosis for TB and toxoplasmosis were also much improved after the implementation of new guidelines. In addition, only 63% of patients had CD4 count test results before the new guidelines compared to 99% of patients after new guidelines. Death odds after the implementation of new guidelines were significantly lower than before new guidelines in a multivariate regression model that included patients CD4 count and 10 other covariates, p < 0.05. CONCLUSIONS: Simplification and implementation of a new and improved HIV clinical guideline coupled with the installation of laboratory equipment and point of care tests potentially helped reduce incorrect diagnosis and improve clinical outcomes of patients with advanced HIV. Regulating authorities should consider developing simplified versions of guidelines followed by the provision of basic diagnostic equipment to health centers.

Contribution des diagnostics au points de service dans l'identification de la maladie à VIH avancée.

BACKGROUND: Médecins Sans Frontières Belgium installed point-of-care (POC) diagnostics for the early detection of advanced HIV disease (AHD), and in its presence, TB and cryptococcosis, in six health centres (Kasai, St Ambroise, St Joseph, Libondi, Lisanga and Kimia) in Kinshasa, Democratic Republic of the Congo (DRC). OBJECTIVE: To document their contribution to the diagnosis of these conditions. METHOD: This is a retrospective cross-sectional study of HIV-positive adolescents and adults admitted with suspected AHD. A comparison 2 years before and 2 years after installation of POC was performed. RESULTS: A total of 745 and 887 patients were included before and after POC, respectively. The mean age was 39.7 years (standard deviation [SD] 12.04); 66% (n = 1,077) were women. Patients with CD4 counts increased from 40.3% (n = 300) to 64.4% (n = 573) (P < 0.001). After the installation of POC, they ranged from 47.8% (Lisanga) to 97.1% (Kasai). The proportion of AHD was comparable (n = 158, 52.7% vs. n = 288, 50.3%; P = 0.779). Among patients with AHD, TB was detected in 28.5% (n = 82), of which 41.5% (n = 34) were confirmed; cryptococcosis was detected in 24.7% (n = 71), of which 9.9% (n = 7) were confirmed. Disparities between centres were observed. CONCLUSION: The POCs have increased patient access to CD4 testing and diagnosis of AHD in the six centres in DRC. However, actions are required to improve this performance, including screening for TB and cryptococcosis.

Expanding the use of dolutegravir-based antiretroviral therapy in multidrug-resistant TB.

The wider availability of dolutegravir (DTG) containing HIV therapy for patients living with multidrug-resistant TB (MDR-TB) presents several advantages. DTG-based antiretroviral therapy (ART) has superior potency, reduces pill burden, and may reduce overall treatment-related toxicity, giving it the potential to improve outcomes in both diseases. While the uptake of DTG-based ART in programs where drug-resistant TB is treated remains unknown, there is early evidence from three programs that uptake is increasing. The use of DTG-based ART should be scaled-up, beginning with antiretroviral-naïve or virologically suppressed patients initiating MDR-TB treatment.