Practices to improve identification of adult antiretroviral therapy failure at the Lighthouse Trust clinic in Lilongwe, Malawi

Abstract

Summary Background Evaluating treatment failure is critical when deciding to modify antiretroviral therapy (ART). Virologic Assessment Forms (VAFs) were implemented in July 2008 as a prerequisite for ordering viral load. The form requires assessment of clinical and immunologic status. Methods Using the Electronic Medical Record (EMR), we retrospectively evaluated patients who met 2006 WHO guidelines for immunologic failure (≥15 years old; on ART ≥6 months; CD4 count <baseline OR CD4 count >50% drop from peak OR CD4 persistently <100 cells) at the Lighthouse Trust clinic from 12/2007–12/2009. We compared virologic screening, VAF implementation and ART modification during the same period using Fisher’s exact tests and unpaired t-tests as appropriate. Results Of 7,000 enrolled ART patients ≥ 15 years old with at least two CD4 counts, 10% had immunologic failure with a median follow-up time on ART of 1.4 years (IQR: 0.8–2.3). Forty (6%) viral loads were ordered: 14 (35%) were detectable (>400 HIV RNA copies/mL) and 1 (7%) patient was switched to second-line therapy. Overall, 259 VAFs were completed: 67% for immunologic failure and 33% for WHO Stage 4 condition. Before VAF implementation, 1% of patients had viral loads drawn during routine care, whereas afterwards, 8% did (p<0.0001; 95% CI 0.03–0.08). Conclusions Clinicians did not identify a large proportion of immunologic failure patients for screening. Implementation of VAFs produced little improvement in virologic screening during routine care. Better training and monitoring systems are needed.

“They provide the right kind of support.”A qualitative study of preferences for differentiated service delivery location among recipients of antiretroviral therapy at Lighthouse Trust in Lilongwe Malawi

“…LT supports the ART program of the Malawi Ministry of Health and provides integrated HIV prevention, treatment, care, and support services in five high-volume Center of Excellence clinics across the country. LT is widely recognized for its innovations and efforts to improve the quality of care over two decades of HIV-related service delivery [15–22]. In urban Lilongwe, LT runs two, large flagship clinics with 25,148 RoC at Martin Preuss Center at Bwaila Hospital and 12,853 at the Lighthouse clinic at Kamuzu Central Hospital.…”

“…This qualitative study may inform service delivery considerations in other low-resource ART programs in the region.MethodsSettingLT supports the ART program of the Malawi Ministry of Health and provides integrated HIV prevention, treatment, care, and support services in five high-volume Center of Excellence clinics across the country. LT is widely recognized for its innovations and efforts to improve the quality of care over two decades of HIV-related service delivery[15][16][17][18][19][20][21][22]. In urban Lilongwe, LT .…”