A nurse-led intervention to improve management of virological failure in public sector HIV clinics in Durban, South Africa: A pre- and post-implementation evaluation.

BACKGROUND: Identification of patients on antiretroviral therapy (ART) with virological failure (VF) and the response in the public health sector remain significant challenges. We previously reported improvement in routine viral load (VL) monitoring after ART commencement through a health system-strengthening, nurse-led 'VL champion' programme as part of a multidisciplinary team in three public sector clinics in Durban, South Africa. OBJECTIVES: To report on the impact of the VL champion model adapted to identify, support and co-ordinate the management of individuals with VF on first-line ART in a setting with limited electronic-based record capacity. METHODS: We evaluated the VL champion model using a controlled before-after study design. A paper-based tool, the 'high VL register', was piloted under the supervision of the VL champion to improve data management, monitoring of counselling support, and enacting of clinical decisions. We abstracted chart and electronic data (TIER.net) for eligible individuals with VF in the year before and after implementation of the programme, and compared outcomes for individuals during these periods. Our primary outcome was successful completion of the VF pathway, defined as a repeat VL <1 000 copies/mL or a change to second-line ART within 6 months of VF. In a secondary analysis, we assessed the completion of each step in the pathway. RESULTS: We identified 60 and 56 individuals in the pre-intervention and post-intervention periods, respectively, with VF who met the inclusion criteria. Sociodemographic and clinical characteristics were similar between the periods. Repeat VL testing was completed in 61.7% and 57.8% of individuals in these two groups, respectively. We found no difference in the proportion achieving our primary outcome in the pre- and post-intervention periods: 11/60 (18.3%; 95% confidence interval (CI) 9 - 28) and 15/56 (22.8%; 95% CI 15 - 38), respectively (p=0.28). In multivariable logistic regression models adjusted for potential confounding factors, individuals in the post-intervention period had a non-significant doubling of the odds of achieving the primary outcome (adjusted odds ratio 2.07; 95% CI 0.75 - 5.72). However, there was no difference in the rates of completion of each step along the first-line VF cascade of care. CONCLUSIONS: This enhanced intervention to improve VF in the public sector using a paper-based data management system failed to achieve significant improvements in first-line VF management over the standard of care. In addition to interventions that better address patient-centred factors that contribute to VF, we believe that there are substantial limitations to and staffing requirements involved in the ongoing utilisation of a paper-based tool. A prioritisation is needed to further expand and upgrade the electronic medical record system with capabilities for prompting staff regarding patients with missed visits and critical laboratory results demonstrating VF.

Urgent need to improve programmatic management of patients with HIV failing first-line antiretroviral therapy.

INTRODUCTION: Delayed identification and response to virologic failure in case of first-line antiretroviral therapy (ART) in resource-limited settings is a threat to the health of HIV-infected patients. There is a need for the implementation of an effective, standardized response pathway in the public sector. DISCUSSION: We evaluated published cohorts describing virologic failure on first-line ART. We focused on gaps in the detection and management of treatment failure, and posited ways to close these gaps, keeping in mind scalability and standardization. Specific shortcomings repeatedly recorded included early loss to follow-up (>20%) after recognized first-line ART virologic failure; frequent delays in confirmatory viral load testing; and excessive time between the confirmation of first-line ART failure and initiation of second-line ART, which exceeded 1 year in some cases. Strategies emphasizing patient tracing, resistance testing, drug concentration monitoring, adherence interventions, and streamlined response pathways for those failing therapy are further discussed. CONCLUSION: Comprehensive, evidence-based, clinical operational plans must be devised based on findings from existing research and further tested through implementation science research. Until this standard of evidence is available and implemented, high rates of losses from delays in appropriate switch to second-line ART will remain unacceptably common and a threat to the success of global HIV treatment programs.

Targeting the third '90': introducing the viral load champion.

Objective: To move closer to achieving the third target of the UNAIDS 90-90-90 goals, we prospectively implemented a viral load (VL) champion (VLC) program aimed at enhancing VL monitoring and recognition of treatment failure. Design: Three clinics in eThekwini, Kwa-Zulu Natal (low-, medium- and high-volume, encompassing 9184 patients overall) were each assigned a VLC. We employed a descriptive analysis (chart audit) to compare the pre-intervention period to a 1-year post-intervention period. The number of patients with a VL test performed 6 and 12 months after the intervention was calculated as a proportion of VL tests due at those time points (VL completion rate). Results: The pre-implementation VL completion rate at the three sites was respectively 68% (140/205 patients), 54% (84/155 patients) and 64% (323/504 patients), and the 6-month post-implementation completion rate increased to 83% (995/1194 patients), 90% (793/878 patients) and 99% (3101/3124 patients) (P < 0.0001 for each site). VL completion rates remained significantly higher at 12 months post-implementation, with an average cumulative VL completion rate of >90% across all facilities. Conclusion: We demonstrate a successful, multifaceted, quality-improvement intervention centered on a clinic-level VLC which, taken to scale, has important implications for attaining the third UNAIDS 90-90-90 target.

Objectif : Dans le but de se rapprocher de l'atteinte de la troisième cible des objectifs 90-90-90 du Programme commun des Nations Unies sur le VIH/Sida (ONUSIDA), nous avons prospectivement mis en œuvre un programme « champion de la charge virale ¼ (VLC) visant à améliorer le suivi de la charge virale (VL) et la reconnaissance de l'échec du traitement.Schéma : Trois centres à eThekwini, Kwa-Zulu Natal (volume faible, moyen et élevé, soit 9184 patients au total), ont été chacun affectés au VLC. Nous employons une analyse descriptive (audit de dossiers) afin de comparer la période avant l'intervention à la période d'un an qui a suivi l'intervention. Le nombre de patients ayant eu un test VL 6 et 12 mois après l'intervention a été calculé comme une proportion de test VL exigibles à ces dates respectivement (taux d'achèvement du VL).Résultats : Le taux d'achèvement du VL avant la mise en route dans trois sites a été de 68% (140/205 patients), 54% (84/155 patients) et 64% (323/504 patients), respectivement, et le taux d'achèvement à 6 mois après la mise en œuvre a augmenté à 83% (995/1194 patients), 90% (793/878 patients) et 99% (3101/3124 patients), respectivement (P < 0,0001 pour chaque site). Les taux d'achèvement du VL sont restés significativement plus élevés à 12 mois après la mise en œuvre, avec un taux cumulé moyen du VL >90% dans toutes les structures.Conclusion : Nous avons montré la qualité d'une intervention d'amélioration réussie à multiples facettes, centrée sur le VLC au niveau des centres qui­à plus grande échelle­a des implications majeures pour l'atteinte de la troisième cible 90-90-90 de l'ONUSIDA.

Objetivo: Con el propósito de avanzar hacia el cumplimiento del tercer elemento del objetivo «90-90-90¼ del Programa Conjunto de las Naciones Unidas sobre el VIH/SIDA (ONUSIDA), se introdujo un programa con un promotor del seguimiento de la viremia, encaminado a reforzar la vigilancia de la concentración vírica y el reconocimiento del fracaso terapéutico.Método: En cada uno de tres consultorios de eThekwini, en Kwa-Zulu Natal (con una carga asistencial baja, intermedia y alta, que cubrían un total de 9184 pacientes) se nombró un promotor del seguimiento de la viremia. Mediante un análisis descriptivo, se comparó el período preintervención con un período posintervención de un año. El número de pacientes en quienes se practicó la viremia a los 6 y 12 meses después de la intervención se calculó como la proporción de las viremias previstas en estos puntos temporales (tasa de compleción de la viremia).Resultados: La tasa de compleción de la viremia en los tres centros fue como sigue: 68% (140/205 pacientes), 54% (84/155 pacientes) y 64% (323/504 pacientes) y a los 6 meses posintervención, esta tasa aumentó respectivamente a 83% (995/1194 pacientes), 90% (793/878 pacientes) y 99% (3101/3124 pacientes) (P < 0,0001 para cada centro). Las tasas de compleción de la viremia permanecieron significativamente más altas a los 12 meses posintervención con una tasa acumulada superior al 90% en todos los establecimientos.Conclusión: Se puso en evidencia una intervención polifacética eficaz de mejoramiento de la calidad centrada en un promotor clínico del seguimiento de la viremia en cada consultorio, cuya aplicación en una escala más amplia, tendría importantes repercusiones en favor del cumplimiento del tercer elemento del objetivo «90-90-90¼ del ONUSIDA.