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1.
AIDS ; 36(5): 711-719, 2022 04 01.
Artigo em Inglês | MEDLINE | ID: mdl-35025819

RESUMO

OBJECTIVES: Assess whether near-point-of-care (POC) viral load testing at the first antenatal care visit (ANC1) increased the proportion of women taking antiretroviral therapy who were virally suppressed at delivery through expedited clinical action. DESIGN: Difference-in-difference analysis. METHODS: At 20 public sector facilities in Zimbabwe, 10 implemented near-POC viral load testing at ANC1 (August 2019 to November 2020) and 10 used centralized viral load testing at ANC1. Study endpoints included time to result received, clinical action, and unsuppressed viral load (UVL; >1000 copies/ml) at delivery. RESULTS: Of 1782 women, only 46% came for ANC1 before their third trimester. Preimplementation, 28% of women received viral load testing at ANC1, increasing to 86% during implementation. In the near-POC viral load arm, women were more likely to receive their result within 30 days of ANC1 sample collection compared with the centralized laboratory arm [54 versus 14%, relative risk (RR): 4.17, 95% confidence interval (CI) 1.82-9.55], as well as receive clinical action among those with UVL (63 versus 8%, RR 7.88; 95% CI 1.53-40.47). However, we did not observe significant changes in risk of UVL at delivery with near-POC viral load (RR 1.02, 95% CI 0.95-1.10). CONCLUSION: ANC1 viral load coverage was initially low. Near-POC viral load testing at ANC1 dramatically improved the timeliness of result receipt by patients and clinical action for those with an UVL. Although we did not observe a significant impact of provision of near-POC viral load at ANC1 on re-suppression at delivery, potentially because of late presentation for ANC1, continued near-POC viral load testing during pregnancy and delivery may reduce UVL and mother-to-child transmission risk.


Assuntos
Infecções por HIV , Sistemas Automatizados de Assistência Junto ao Leito , Feminino , Infecções por HIV/diagnóstico , Infecções por HIV/tratamento farmacológico , Humanos , Transmissão Vertical de Doenças Infecciosas/prevenção & controle , Masculino , Testes Imediatos , Gravidez , Carga Viral/métodos , Viremia/diagnóstico
2.
AIDS ; 35(15): 2531-2537, 2021 12 01.
Artigo em Inglês | MEDLINE | ID: mdl-34310372

RESUMO

OBJECTIVES: Near-point-of-care (POC) testing for early infant diagnosis (EID) and viral load expedites clinical action and improves outcomes but requires capital investment. We assessed whether excess capacity on existing near-POC devices used for TB diagnosis could be leveraged to increase near-POC HIV molecular testing, termed integrated testing, without compromising TB services. DESIGN: Preimplementation/postimplementation studies in 10 health facilities in Malawi and 8 in Zimbabwe. METHODS: Timeliness of EID and viral load test results and clinical action were compared between centralized and near-POC testing using Somers' D tests (continuous indicators) and risk ratios (RR, binary indicators); TB testing/treatment rates and timeliness were analyzed preintegration/postintegration. RESULTS: With integration, average device utilization increased but did not exceed 55%. Despite the addition of HIV testing, TB test volumes, timeliness, and treatment initiations were maintained. Although few HIV-positive infants were identified, near-POC EID testing improved treatment initiation within 1 month by 57% compared with centralized EID [Malawi RR: 1.57, 95% confidence interval (CI) 0.98-2.52], and near-POC viral load testing significantly increased the proportion of patients with elevated viral load receiving clinical action within 1 month (Zimbabwe RR: 5.26, 95% CI 3.38-8.20; Malawi RR: 3.90, 95% CI 2.58-5.91). CONCLUSION: Integrating TB/HIV testing using existing multidisease platforms is feasible and enables increased access to rapid diagnostics without disrupting existing TB services. Our results serve as an example of a novel, efficient implementation model that can increase access to critical testing services across disease silos and should be considered for additional clinical applications.


Assuntos
Infecções por HIV , Tuberculose , Diagnóstico Precoce , Estudos de Viabilidade , Infecções por HIV/diagnóstico , Teste de HIV , Humanos , Lactente , Malaui , Sistemas Automatizados de Assistência Junto ao Leito , Testes Imediatos , Tuberculose/diagnóstico , Zimbábue
4.
J Int AIDS Soc ; 24(1): e25663, 2021 01.
Artigo em Inglês | MEDLINE | ID: mdl-33455081

RESUMO

INTRODUCTION: In many low- and middle-income countries, HIV viral load (VL) testing occurs at centralized laboratories and time-to-result-delivery is lengthy, preventing timely monitoring of HIV treatment adherence. Near point-of-care (POC) devices, which are placed within health facility laboratories rather than clinics themselves (i.e. "true" POC), can offer VL in conjunction with centralized laboratories to expedite clinical decision making and improve outcomes, especially for patients at high risk of treatment failure. We assessed impacts of near-POC VL testing on result receipt and clinical action in public sector programmes in Cameroon, Democratic Republic of Congo, Kenya, Malawi, Senegal, Tanzania and Zimbabwe. METHODS: Routine health data were collected retrospectively after introducing near-POC VL testing at 57 public sector health facilities (2017 to 2019, country-dependent). Where possible, key indicators were compared to data from patients receiving centralized laboratory testing using hazard ratios and the Somers' D test. RESULTS: Data were collected from 6795 tests conducted on near-POC and 17614 tests on centralized laboratory-based platforms. Thirty-one percent (2062/6694) of near-POC tests were conducted for high-risk populations: pregnant and breastfeeding women, children and those with suspected failure. Compared to conventional testing, near-POC improved the median time from sample collection to return of results to patient [six vs. sixty-eight days, effect size: -32.2%; 95% CI: -41.0% to -23.4%] and to clinical action for individuals with an elevated HIV VL [three vs. fourty-nine days, effect size: -35.4%; 95% CI: -46.0% to -24.8%]. Near-POC VL results were two times more likely to be returned to the patient within 90 days compared to centralized tests [50% (1781/3594) vs. 27% (4172/15271); aHR: 2.22, 95% CI: 2.05 to 2.39]. Thirty-seven percent (340/925) of patients with an elevated near-POC HIV VL result had documented clinical follow-up actions within 30 days compared to 7% (167/2276) for centralized testing. CONCLUSIONS: Near-POC VL testing enabled rapid test result delivery for high-risk populations and led to significant improvements in the timeliness of patient result receipt compared to centralized testing. While there was some improvement in time-to-clinical action with near-POC VL testing, major gaps remained. Strengthening of systems supporting the utilization of results for patient management are needed to truly capitalize on the benefits of decentralized testing.


Assuntos
Infecções por HIV/virologia , Sistemas Automatizados de Assistência Junto ao Leito , Carga Viral , Adolescente , Adulto , África ao Sul do Saara , Idoso , Criança , Pré-Escolar , Feminino , Infecções por HIV/tratamento farmacológico , Instalações de Saúde , Humanos , Lactente , Recém-Nascido , Masculino , Pessoa de Meia-Idade , Gravidez , Prática de Saúde Pública , Estudos Retrospectivos , Carga Viral/métodos , Adulto Jovem
5.
J Infect Dev Ctries ; 14(8): 893-900, 2020 08 31.
Artigo em Inglês | MEDLINE | ID: mdl-32903234

RESUMO

INTRODUCTION: The isoniazid-resistant TB poses a threat to TB control efforts. Zimbabwe, one of the high TB burden countries, has not explored the burden of isoniazid resistant TB. Hence among all bacteriologically-confirmed TB patients diagnosed in Bulawayo City during March 2017 and December 2018, we aimed to assess the proportion with isoniazid resistant TB and associated factors. Also, we aimed to describe the TB treatment outcomes. METHODOLOGY: A cohort study involving routinely collected data by the National TB Reference Laboratory (NTBRL) in Bulawayo City and National TB programme of Zimbabwe. The percentage with 95% confidence interval (CI) was used to express the proportion with isoniazid-resistant TB. The modified Poisson regression was used to assess the association of demographic and clinical characteristics with isoniazid mono-resistant TB. RESULTS: Of 2160 bacteriologically-confirmed TB patients, 1612 (74.6%) had their sputum received at the NTBRL and 743 (46.1%) had culture growth. Among those with culture growth, 34 (4.6%, 95% CI: 3.5-6.7) had isoniazid mono-resistant TB, 25 (3.3%, 95% CI: 2.2-4.9) had MDR-TB. Thus, 59 (7.9%, 95% CI: 6.1-10.1) had isoniazid-resistant TB. Children < 15 years had a higher prevalence of isoniazid mono-resistant TB (aPR= 3.93; 95% CI: 1.24-12.45). Among those with rifampicin sensitive TB, patients with isoniazid-sensitive TB had higher favourable treatment outcomes compared to those with isoniazid-resistant TB (86.3% versus 75.5%, p = 0.039). CONCLUSIONS: The prevalence of isoniazid-resistant TB was low compared to neighbouring countries with high burden of TB-HIV. However, Zimbabwe should consider reviewing treatment guidelines for isoniazid mono-resistant TB due to the observed poor treatment outcomes.


Assuntos
Mycobacterium tuberculosis/efeitos dos fármacos , Tuberculose Resistente a Múltiplos Medicamentos/epidemiologia , Adolescente , Adulto , Feminino , Infecções por HIV/epidemiologia , Humanos , Isoniazida/uso terapêutico , Masculino , Pessoa de Meia-Idade , Mycobacterium tuberculosis/isolamento & purificação , Estudos Retrospectivos , Resultado do Tratamento , Tuberculose Resistente a Múltiplos Medicamentos/tratamento farmacológico , Adulto Jovem , Zimbábue/epidemiologia
8.
Afr J Lab Med ; 5(2): 535, 2016.
Artigo em Inglês | MEDLINE | ID: mdl-28879129

RESUMO

Point-of-care (POC) tests have been useful in increasing access to testing and treatment monitoring for HIV. Decentralising testing from laboratories to hundreds of sites around a country presents tremendous challenges in training and quality assurance. In order to address these concerns, companies are now either embedding connectivity in their new POC diagnostic instruments or providing some form of channel for electronic result exchange. These will allow automated key performance and operational metrics from devices in the field to a central database. Setting up connectivity between these POC devices and a central database at the Ministries of Health will allow automated data transmission, creating an opportunity for real-time information on diagnostic instrument performance as well as the competency of the operator through external quality assessment. A pilot programme in Zimbabwe shows that connectivity has significantly improve the turn-around time of external quality assessment result submissions and allow corrective actions to be provided in a timely manner. Furthermore, by linking the data to existing supply chain management software, stock-outs can be minimised. As countries are looking forward to achieving the 90-90-90 targets for HIV, such innovative technologies can automate disease surveillance, improve the quality of testing and strengthen the efficiency of health systems.

9.
Afr J Lab Med ; 3(2): 241, 2014.
Artigo em Inglês | MEDLINE | ID: mdl-29043196

RESUMO

BACKGROUND: Laboratory mentorship has proven to be an effective tool in building capacity and assisting laboratories in establishing quality management systems. The Zimbabwean Ministry of Health and Child Welfare implemented four mentorship models in 19 laboratories in conjunction with the Strengthening Laboratory Management Toward Accreditation (SLMTA) programme. OBJECTIVES: This study outlines how the different models were implemented, cost involved per model and results achieved. METHODS: Eleven of the laboratories had been trained previously in SLMTA (Cohort I). They were assigned to one of three mentorship models based on programmatic considerations: Laboratory Manager Mentorship (Model 1, four laboratories); One Week per Month Mentorship (Model 2, four laboratories); and Cyclical Embedded Mentorship (Model 3, three laboratories). The remaining eight laboratories (Cohort II) were enrolled in Cyclical Embedded Mentorship incorporated with SLMTA training (Model 4). Progress was evaluated using a standardised audit checklist. RESULTS: At SLMTA baseline, Model 1-3 laboratories had a median score of 30%. After SLMTA, at mentorship baseline, they had a median score of 54%. At the post-mentorship audit they reached a median score of 75%. Each of the three mentorship models for Cohort I had similar median improvements from pre- to post-mentorship (17 percentage points for Model 1, 23 for Model 2 and 25 for Model 3; p > 0.10 for each comparison). The eight Model 4 laboratories had a median baseline score of 24%; after mentorship, their median score increased to 63%. Median improvements from pre-SLMTA to post-mentorship were similar for all four models. CONCLUSION: Several mentorship models can be considered by countries depending on the available resources for their accreditation implementation plan.

10.
Afr J Lab Med ; 3(2): 248, 2014.
Artigo em Inglês | MEDLINE | ID: mdl-29043197

RESUMO

BACKGROUND: In 2010, the Zimbabwe Ministry of Health and Child Welfare (MoHCW) adopted the Strengthening Laboratory Management Toward Accreditation (SLMTA) programme as a tool for laboratory quality systems strengthening. OBJECTIVES: To evaluate the financial costs of SLMTA implementation using two models (external facilitators; and internal local or MoHCW facilitators) from the perspective of the implementing partner and to estimate resources needed to scale up the programme nationally in all 10 provinces. METHODS: The average expenditure per laboratory was calculated based on accounting records; calculations included implementing partner expenses but excluded in-kind contributions and salaries of local facilitators and trainees. We also estimated theoretical financial costs, keeping all contextual variables constant across the two models. Resource needs for future national expansion were estimated based on a two-phase implementation plan, in which 12 laboratories in each of five provinces would implement SLMTA per phase; for the internal facilitator model, 20 facilitators would be trained at the beginning of each phase. RESULTS: The average expenditure to implement SLMTA in 11 laboratories using external facilitators was approximately US$5800 per laboratory; expenditure in 19 laboratories using internal facilitators was approximately $6000 per laboratory. The theoretical financial cost of implementing a 12-laboratory SLMTA cohort keeping all contextual variables constant would be approximately $58 000 using external facilitators; or $15 000 using internal facilitators, plus $86 000 to train 20 facilitators. The financial cost for subsequent SLMTA cohorts using the previously-trained internal facilitators would be approximately $15 000, yielding a break-even point of 2 cohorts, at $116 000 for either model. Estimated resources required for national implementation in 120 laboratories would therefore be $580 000 using external facilitators ($58 000 per province) and $322 000 using internal facilitators ($86 000 for facilitator training in each of two phases plus $15 000 for SLMTA implementation in each province). CONCLUSION: Investing in training of internal facilitators will result in substantial savings over the scale-up of the programme. Our study provides information to assist policy makers to develop strategic plans for investing in laboratory strengthening.

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