Not yet 90-90-90: A quality improvement approach to human immunodeficiency virus viral suppression in paediatric patients in the rural Eastern Cape, South Africa

Abstract

Background: A strategy implemented by the South African Department of Health to manage the high burden of human immunodeficiency virus (HIV) has been to task-shift services to primary health care clinics. Outcomes of paediatric patients with HIV are poorer than those of adults, particularly in rural areas. Viral suppression in paediatric patients at the feeder clinics of a rural South African hospital was anecdotally far below the aim of the Joint United Nations Programme on HIV/AIDS (UNAIDS) of 90%.Methods: A quality improvement approach was used to conduct a baseline assessment of HIV viral suppression in paediatric patients and other process measures, implement a clinical mentorship intervention and evaluate its effectiveness.Results: An initial audit of 235 clinical folders of paediatric patients with HIV revealed a viral suppression of 55.3%. Other poor measures included prescription accuracy, viral loads performed within schedule and response to successive high viral loads. A clinical mentorship intervention using dedicated doctor outreach was implemented and the audit repeated after 12 months (263 folders). Viral suppression improved to 67.4%, as did most other process measures.Conclusion: The quality improvement approach regarding the aim to significantly improve viral suppression in paediatric patients through the implementation of clinical mentorship was successful.

Risk factors for sustained virological non-suppression among children and adolescents living with HIV in Zimbabwe and Malawi: a secondary data analysis

“…Solutions could include training and mentoring of staff on diagnosing and managing regimen changes; implementing new developments such as point of care viral load testing, when available and approved, so that the short turnaround time can assist with more rapid management of abnormal results; procuring new drug formulations with improved tolerability and pill burden, when available; and thorough counselling of patients and their families on the importance of adhering to the second line regimen. In rural South Africa, quality improvement and clinical mentorship led to more children being switched to second line therapies [ 24 ].…”

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“…Several barriers exist to the achievement of viral suppression among children. These include poor adherence due to the side effects and nonpalatability of some available formulations [5,6], dependence on caregivers for ART pick-up at a health facility or to administer medication [7], confidentiality around the HIV status of the child, food requirements for some regimens [8], nondisclosure, forgetfulness [9], and transport to health facility [10]. While adherence interventions have been found to improve VL suppression in up to 70% of children failing first-line regimens [11][12][13], only a limited number of studies have been conducted in Nigeria -a country with one of the highest numbers of children living with HIV-to assess the impact of targeted interventions among this population.…”

Strategies for Improving Viral Suppression among Children Living with HIV Considered to be Failing First-Line Antiretroviral Therapy in Akwa Ibom, Nigeria: A before - after Study

“…Several barriers exist to the achievement of viral suppression among children. These include poor adherence due to the side effects and nonpalatability of some available formulations [5,6], dependence on caregivers for ART pick-up at a health facility or to administer medication [7], confidentiality around the HIV status of the child, food requirements for some regimens [8], nondisclosure, forgetfulness [9], and transport to health facility [10]. While adherence interventions have been found to improve VL suppression in up to 70% of children failing first-line regimens [11][12][13], only a limited number of studies have been conducted in Nigeria -a country with one of the highest numbers of children living with HIV-to assess the impact of targeted interventions among this population.…”