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

Abstract

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.

Detection of HIV Virologic Failure and Switch to Second-Line Therapy: A Systematic Review and Meta-analysis of Data From Sub-Saharan Africa

“…This requirement, while reducing some unnecessary second-line ART switching, introduces an inherent delay in establishing treatment failure. Third, the health care worker responsible for responding to elevated viral load values has not, in some clinics, been clearly identified [ 16 ]. This responsibility is critical because an elevated viral load requires a deliberate set of interventions, including a return visit, an adherence intervention, and repeat viral load testing, which, our research demonstrates, currently plays out over not weeks—as was anticipated in treatment guidelines—but months.…”

“…Although viral load testing clearly improves the quality of HIV care, health services research is needed to help direct how to deploy it better. For example, a marked improvement in viral load testing rates was observed in clinics in South Africa that deployed a nurse-led “viral load champion” program [ 16 ]. Using this approach, overall detection of virologic treatment failure improved rapidly in a programmatic setting without additional human resources.…”

Intervention strategies to improve adherence to treatment for selected chronic conditions in sub‐Saharan Africa: a systematic review

“…The reasons for the exclusion of papers are noted in Figure 1. In total, 82 articles [27–108] were found to be eligible and data were then extracted (Supplementary Material 4).…”

Management technology for implementing the Systematization of Nursing Care

“…This context needs to be directed to reflection on the necessary conditions for nursing staff sizing, with a view to transposing the work environment and including ethical and political aspects of the nursing work process, essential for SNC to be implemented ( 26 ) . Therefore, when the organization of nursing work is compatible and adequate, the benefits to society may be even greater, especially given the fact that nursing professionals may be well positioned to lead critical context management programs, as in Africa, due to HIV control ( 27 ) , or for improving performance management/performance of Primary Health Care nurses ( 28 ) . Furthermore, as it constitutes a pillar of SNC, the elements related to human resources in nursing need to be carefully respected so that there is well-being and quality of life at work in nursing, especially in critical contexts, such as a pandemic, which can be better faced through the understanding and practical operation of defining and differentiating contours ( 29 ) .…”