A Packaged Intervention to Improve Viral Load Monitoring within a Deeply Rural Health District of South Africa

Abstract

Background: The KwaZulu-Natal (KZN) province of South Africa has the highest prevalence of HIV infection in the world. Viral load (VL) testing is a crucial tool for clinical and programmatic monitoring. Within uMkhanyakude district, VL suppression rates were 91% among patients with VL data; however, VL performance rates averaged only 38•7%. The objective of this study was to determine if enhanced clinic processes and community outreach could improve VL monitoring within this district. Methods: A packaged intervention was implemented at three rural clinics in the setting of the KZN HIV AIDS Drug Resistance Surveillance Study. This included le hygiene, outreach, a VL register and documentation revisions. Chart audits were used to assess delity. Outcome measures included percentage VL performed and suppressed. Each rural clinic was matched with a peri-urban clinic for comparison before and after the start of each phase of the intervention. Monthly sample proportions were modelled using quasi-likelihood regression methods for over-dispersed binomial data. Results: Mkuze and Jozini clinics increased VL performance overall from 33•9% and 35•3% to 75•8% and 72•4%, respectively which was signi cantly greater than the increases in the comparison clinics (RR 1•86 and 1•68, p<0•01). VL suppression rates similarly increased overall by 39•3% and 36•2% (RR 1•84 and 1•70, p<0•01). The Chart Intervention phase showed signi cant increases in delity 16 months after implementation. Conclusions: The packaged intervention improved VL performance and suppression rates overall but was signi cant in Mkuze and Jozini. Larger sustained efforts will be needed to have a similar impact throughout the province.

Tenofovir diphosphate levels in dried blood spots are associated with virologic failure and resistance to first‐line therapy in South Africa: a case–control cohort study

“…A total of 1000 treatment-naïve PWH who initiated first-line ART (TDF/FTC/EFV or TDF/FTC plus NVP [n = 6]) at RK K (n = 500) and BTD (n = 500) enrolled into the parent study [25]. For this analysis, we included data from 288 (29%) participants in whom drug concentrations were available (n = 1 on NVP).…”

“…Treatment naïve PWH ≥18 years, who initiated first-line ART according to the South African National HIV guidelines, were enrolled into the KZN HIV AIDS Drug Resistance Surveillance Study (ADReSS) [25]. ART consisting of TDF and emtricitabine (FTC), plus EFV (as a single-table regimen) or nevirapine (NVP) [25] was provided by South African health authorities.…”

“…Treatment naïve PWH ≥18 years, who initiated first-line ART according to the South African National HIV guidelines, were enrolled into the KZN HIV AIDS Drug Resistance Surveillance Study (ADReSS) [25]. ART consisting of TDF and emtricitabine (FTC), plus EFV (as a single-table regimen) or nevirapine (NVP) [25] was provided by South African health authorities. PWH were excluded if they had received any prior ART (including pre-or post-exposure prophylaxis), but singledose NVP for the prevention of mother-to-child transmission was permitted.…”

“…PWH were excluded if they had received any prior ART (including pre-or post-exposure prophylaxis), but singledose NVP for the prevention of mother-to-child transmission was permitted. Study participants were prospectively enrolled at two clinical centres, RK Khan (RKK) regional hospital and Bethesda (BTD) hospital in KZN, as previously described [25]. Enrolment initiated in July 2014 and was completed in September 2016.…”

“…The study team assessed the health records and available data (including the National Health Laboratory System and the Department of Home Affairs data base) to determine the vital status of participants who were lost to follow-up. Blood for VL at 6 and 12 months after ART initiation (followed by yearly intervals) was obtained per local standard of care [25] or until participants developed VF. Local guidelines defined VF as two consecutive HIV-1 RNA >1000 copies/ml obtained ≥2 months apart after intensive adherence counselling.…”