Journey towards universal viral load monitoring in Maputo, Mozambique: many gaps, but encouraging signs

Swannet, Sarah; Decroo, Tom; Castro, Sheila M T L de; Rose, Caroline J.; Giuliani, Ruggero; Molfino, Lucas; Torrens, Ana; Macueia, Walter S E D; Perry, Sharon; Reid, Tony

doi:10.1093/inthealth/ihx021

Cited by 29 publications

(40 citation statements)

References 21 publications

(29 reference statements)

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“…Even when high VL-testing coverage is achieved, good HIV treatment outcomes will remain out of reach if effective follow-up of suspected failure patients does not occur. Our follow-up testing rate among suspected failures (83%) was similar to recent findings in Lesotho (85%) and notably higher than rates reported previously in Swaziland (70%), Malawi (30%), Mozambique (35%) or Siaya County, Kenya (35%), [17,50,51,[53][54][55]. Notably, less than one-third of suspect failures had a suppressed VL at their first follow-up test, likely corresponding to high levels of acquired first-line drug resistance in this mature cohort where VL-monitoring was only recently introduced, as reported in similar settings [17,25,34,35,50,54,56,57].…”

Section: Discussionsupporting

confidence: 89%

“…Notably, a recent clinical trial reported higher rates of retention, VL-suppression and referral to decentralized care in patients who received POC-VL-testing [66]. Yet, our findings (and others [17,50,53,54,56]) indicate that providing access to the technology is not enough. Regular staff training, mentoring and VL "focal-points" who monitor testing protocols are recommended.…”

Section: Discussioncontrasting

confidence: 68%

“…Previous reports from sub‐Saharan African settings have consistently shown low and delayed switching from first‐ to second‐line ART (even when VL‐monitoring is present), which have been linked to poorer treatment outcomes, increased mortality and the risk of the development and transmission of resistance . In our sites, 80% of first‐line treatment failures were switched to second‐line, an encouraging figure that is higher than in similar programmes (43%, Swaziland; 33%, Mozambique ). However, even 80% is insufficient.…”

Section: Discussionsupporting

confidence: 55%

“…Previous reports from sub-Saharan African settings have consistently shown low and delayed switching from first-to second-line ART (even when VL-monitoring is present), which have been linked to poorer treatment outcomes, increased mortality and the risk of the development and transmission of resistance [8,32,[60][61][62][63]. In our sites, 80% of first-line treatment failures were switched to second-line, an encouraging figure that is higher than in similar programmes (43%, Swaziland; 33%, Mozambique [50,64] three-test failure algorithm or the non-capture of VL-tests in the electronic database. Encouragingly, in 2016 MOH guidelines lowered the failure confirmation threshold from 5000 to 1000 cps/mL [45], and since 2018 follow-up VL-testing for suspect failures is independent of good adherence [46], thus further streamlining VL scale-up.…”

Section: Discussionmentioning

confidence: 51%

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Point‐of‐care viral load monitoring: outcomes from a decentralized HIV programme in Malawi

Nicholas¹,

Poulet²,

Wolters³

et al. 2019

J Intern AIDS Soc

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Introduction Routinely monitoring the HIV viral load ( VL ) of people living with HIV ( PLHIV ) on anti‐retroviral therapy ( ART ) facilitates intensive adherence counselling and faster ART regimen switch when treatment failure is indicated. Yet standard VL ‐testing in centralized laboratories can be time‐intensive and logistically difficult in low‐resource settings. This paper evaluates the outcomes of the first four years of routine VL ‐monitoring using Point‐of‐Care technology, implemented by Médecins Sans Frontières ( MSF ) in rural clinics in Malawi. Methods We conducted a retrospective cohort analysis of patients eligible for routine VL ‐ testing between 2013 and 2017 in four decentralized ART ‐clinics and the district hospital in Chiradzulu, Malawi. We assessed VL ‐testing coverage and the treatment failure cascade (from suspected failure (first VL >1000 copies/ mL ) to VL suppression post regimen switch). We used descriptive statistics and multivariate logistic regression to assess factors associated with suspected failure. Results and Discussion Among 21,400 eligible patients, VL ‐testing coverage was 85% and VL suppression was found in 89% of those tested. In the decentralized clinics, 88% of test results were reviewed on the same day as blood collection, whereas in the district hospital the median turnaround‐time for results was 85 days. Among first‐line ART patients with suspected failure (N = 1544), 30% suppressed ( VL <1000 copies/ mL ), 35% were treatment failures (confirmed by subsequent VL ‐testing) and 35% had incomplete VL follow‐up. Among treatment failures, 80% (N = 540) were switched to a second‐line regimen, with a higher switching rate in the decentralized clinics than in the district hospital (86% vs. 67%, p < 0.01) and a shorter median time‐to‐switch (6.8 months vs. 9.7 months, p < 0.01). Similarly, the post‐switch VL ‐testing rate was markedly higher in the decentralized clinics (61% vs. 26%, p < 0.01). Overall, 79% of patients with a post‐switch VL ‐test were suppressed. Conclusions Viral load testing at the point‐of‐care in Chiradzulu, Malawi achieved high coverage and good drug regimen switch rates among those identified as treatment failures. In...

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Section: Discussionsupporting

confidence: 89%

Section: Discussioncontrasting

confidence: 68%

Section: Discussionsupporting

confidence: 55%

Section: Discussionmentioning

confidence: 51%

See 2 more Smart Citations

Point‐of‐care viral load monitoring: outcomes from a decentralized HIV programme in Malawi

Nicholas¹,

Poulet²,

Wolters³

et al. 2019

J Intern AIDS Soc

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“…The uptake of routine VL monitoring among the patients ranged from 3% to 95% in seven sub-Saharan countries 10. Studies reported that there were individual and programme level factors which influenced the uptake of VL testing by the patients 11 12…”

Section: Introductionmentioning

confidence: 99%

Uptake of routine viral load testing among people living with HIV and its implementation challenges in Yangon region of Myanmar: a mixed-methods study

Thinn

Thekkur

Kyaw³

et al. 2019

BMJ Open

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ObjectivesIn 2017, Myanmar implemented routine viral load (VL) monitoring for assessing the response to antiretroviral therapy (ART) among people living with HIV (PLHIV). The performance of routine VL testing and implementation challenges has not yet assessed. We aimed to determine the uptake of VL testing and factors associated with it among PLHIV initiated on ART during 2017 in ART clinics of Yangon region and to explore the implementation challenges as perceived by the healthcare providers.DesignAn explanatory mixed-methods study was conducted. The quantitative component was a cohort study, and the qualitative part was a descriptive study with in-depth interviews.SettingSix ART clinics operated by AIDS/sexually transmitted infection teams under the National AIDS Programme.Primary outcome measures(1) The proportion who underwent VL testing by 30 March 2019 and the proportion with virological suppression (plasma VL <1000 copies/mL); (2) association between patient characteristics and ‘not tested’ was assessed using log binomial regression and (3) qualitative codes on implementation challenges.ResultsOf the 567 PLHIV started on ART, 498 (87.8%) retained in care for more than 6 months and were eligible for VL testing. 288 (57.8%, 95% CI: 53.3% to 62.2%) PLHIV underwent VL testing, of which 263 (91.3%, 95% CI: 87.1% to 94.4%) had virological suppression. PLHIV with WHO clinical stage 4 had significantly higher rates of ‘not being tested’ for VL. Collection of sample for VL testing only twice a month, difficulties in sample collection and transportation, limited trained workforce, wage loss and out-of-pocket expenditure for patients due to added visits were major implementation challenges.ConclusionsThe VL test uptake was low, with only six out of ten PLHIV tested. The VL testing uptake needs to be improved by strengthening sample collection and transportation, adopting point-of-care VL tests, increasing trained workforce, providing compensation to patients for wage loss and travel costs for additional visits.

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Experiences, perceptions and potential impact of community‐based mentor mothers supporting pregnant and postpartum women with HIV in Kenya: a mixed‐methods study

et al. 2021

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IntroductionCommunity‐based mentor mothers (cMMs) are women living with HIV who provide peer support to pregnant/postpartum women living with HIV (PWLWH) to enhance antiretroviral therapy (ART) adherence, retention in care and prevent perinatal transmission of HIV. The goal of this study was to explore the experiences, perceptions, mechanisms and health impact of cMMs on PWLWH in Kenya from the perspective of cMMs.MethodsWe conducted a prospective mixed‐methods study in southwestern Kenya in 2015–2018. In the qualitative phase, we completed in‐depth interviews with cMMs to explore their perceptions and experiences in supporting PWLWH. Transcripts were broad‐coded according to identified themes, then fine‐coded using an inductive approach. In the quantitative phase, we analysed medical record data from PWLWH who were randomized in the cMM intervention to examine the impact of cMM visits on optimal prevention of mother‐to‐child transmission (PMTCT). We used cluster‐adjusted generalized estimating equation models to examine relationships with a composite outcome (facility delivery, infant HIV testing, ART adherence and undetectable viral load at 6 weeks postpartum). Finally, qualitative and quantitative results were integrated.ResultsConvergence of findings from cMM interviews (n= 24) and PWLWH medical data (n= 589) revealed: (1) The cMM intervention was utilized and perceived as acceptable. PWLWH received, on average, 6.2 of 8 intended home visits through 6 weeks postpartum. (2) The cMMs reported serving as role models and confidantes, supporting PWLWH's acceptance of their HIV status, providing assurances about PMTCT and assisting with male partner disclosure and communication. cMMs also described benefits for themselves, including empowerment and increased income. (3) The cMM visits supported PWLWH's completion of PMTCT steps. Having ≥4 cMM home visits up to 6 weeks postpartum, as compared to <4 visits, was associated with higher likelihood of an optimal PMTCT composite outcome (adjusted relative risk 1.42,p= 0.044).ConclusionsWe found that peer support from cMMs during pregnancy through 6 weeks postpartum was associated with improved uptake of critical PMTCT services and health behaviours and was perceived as beneficial for cMMs themselves. CMM support of PWLWH may be valuable for other low‐resource settings to improve engagement with lifelong ART and HIV services among PWLWH.

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Journey towards universal viral load monitoring in Maputo, Mozambique: many gaps, but encouraging signs

Cited by 29 publications

References 21 publications

Point‐of‐care viral load monitoring: outcomes from a decentralized HIV programme in Malawi

Point‐of‐care viral load monitoring: outcomes from a decentralized HIV programme in Malawi

Uptake of routine viral load testing among people living with HIV and its implementation challenges in Yangon region of Myanmar: a mixed-methods study

Experiences, perceptions and potential impact of community‐based mentor mothers supporting pregnant and postpartum women with HIV in Kenya: a mixed‐methods study

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