Targeting the third ‘90’: introducing the viral load champion

Sunpath, Henry; Hatlen, Timothy; Naidu, Kevindra; Msimango, P; Adams, Rochelle; Moosa, M-Y S; Marconi, Vincent C.; Murphy, Richard A.; Gandhi, Rajesh T.; Pillay, Sandy; Siedner, Mark J.; Naidoo, Kogieleum

doi:10.5588/pha.18.0063

Cited by 24 publications

(34 citation statements)

References 11 publications

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“…Strategies to improve uptake of VL testing including point-of-care testing [28], identifying VL focal persons to flag those in need of VL testing, enhanced adherence counseling, patient education, and demand creation for VL testing, are needed to improve coverage of viral suppression and HIV epidemic control in resource-limited settings [29]. A VL champion program increased testing uptake in South Africa from 64 to 90% after 6 months [24]. Quality improvement tools focused on providers and patients improved VL testing uptake in Malawi [26].…”

Section: Discussionmentioning

confidence: 99%

“…Our finding that 33% of PWH on ART did not receive a VL test in 2017 is in agreement with prior work in South Africa in which 42, 32, and 26% that did not receive VL testing 6 months, 1 year and 2 years, respectively, after starting treatment [ 24 ]. Leakages in the VL cascade were observed in Mozambique where non-uptake of a first VL test was 60% in 2015 [ 13 ] and in Cameroon where VL non-uptake was 76% in 2017 [ 25 ].…”

Section: Discussionmentioning

confidence: 99%

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Non-uptake of viral load testing among people receiving HIV treatment in Gomba district, rural Uganda

et al. 2020

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Background Viral load (VL) testing is the gold-standard approach for monitoring human immunodeficiency virus (HIV) treatment success and virologic failure, but uptake is suboptimal in resource-limited and rural settings. We conducted a cross-sectional study of risk factors for non-uptake of VL testing in rural Uganda. Methods We conducted a cross-sectional analysis of uptake of VL testing among randomly selected people with HIV (PWH) receiving anti-retroviral treatment (ART) for at least 6 months at all eight primary health centers in Gomba district, rural Uganda. Socio-demographic and clinical data were extracted from medical records for the period January to December 2017. VL testing was routinely performed 6 months after ART initiation and 12 months thereafter for PWH stable on ART. We used descriptive statistics and multivariable logistic regression to evaluate factors associated with non-uptake of VL testing (the primary outcome). Results Of 414 PWH, 60% were female, and the median age was 40 years (interquartile range [IQR] 31–48). Most (62.3%) had been on ART > 2 years, and the median duration of treatment was 34 months (IQR 14–55). Thirty three percent did not receive VL testing: 36% of women and 30% of men. Shorter duration of ART (≤2 years) (adjusted odds ratio [AOR] 2.38; 95% CI:1.37–4.12; p = 0.002), younger age 16–30 years (AOR 2.74; 95% CI:1.44–5.24; p = 0.002) and 31–45 years (AOR 1.92; 95% CI 1.12–3.27; p = 0.017), and receipt of ART at Health Center IV (AOR 2.85; 95% CI: 1.78–4.56; p < 0.001) were significantly associated with non-uptake of VL testing. Conclusions One-in-three PWH on ART missed VL testing in rural Uganda. Strategies to improve coverage of VL testing, such as VL focal persons to flag missed tests, patient education and demand creation for VL testing are needed, particularly for recent ART initiates and younger persons on treatment, in order to attain the third Joint United Nations Program on HIV/AIDS (UNAIDS) 95–95-95 target – virologic suppression for 95% of PWH on ART.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Non-uptake of viral load testing among people receiving HIV treatment in Gomba district, rural Uganda

et al. 2020

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“…Therefore, ART programs need to combine roll-out of VL monitoring with strategies that ensure that patients with virological failure are followed-up and that confirmed virological failure results in action, in order to achieve virological re-suppression[3,7,19,20]. Sunpath and colleagues showed in three clinics in South Africa that introduction of a “viral load champion”, a nurse who was specifically assigned to ensure correct follow-up of VLs, resulted in a higher proportion monitored according to schedule[21]. Venables et al report that SMS alerts to clinics and patients when VL results are out was well perceived and could have the potential to help patients adopt a more active role in the self-management of their HIV disease [22].…”

Section: Discussionmentioning

confidence: 99%

The viral load monitoring cascade in a resource-limited setting: A prospective multicentre cohort study after introduction of routine viral load monitoring in rural Lesotho

Glass

Motaboli²,

Nsakala³

et al. 2019

PLoS ONE

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Introduction For HIV-positive individuals on antiretroviral therapy (ART), the World Health Organization (WHO) recommends routine viral load (VL) monitoring. We report on the cascade of care in individuals with unsuppressed VL after introduction of routine VL monitoring in a district in Lesotho. Materials and methods In Butha-Buthe district 12 clinics (11 rural, 1 hospital) send samples for VL testing to the district laboratory. We included data from patients aged ≥15 years from Dec 1, 2015 to November 1, 2018. As per WHO guidelines VL <1000 copies/mL are considered suppressed, those ≥1000copies/mL unsuppressed. Patients with unsuppressed VL receive adherence counseling and follow-up VL within 8–12 weeks. Two consecutively unsuppressed VLs should trigger switch to second-line ART. For analysis of the VL monitoring cascade we defined care to be “according to guidelines” if patients with unsuppressed VL received a follow-up VL within <180 days and follow-up VL was either re-suppressed, or again unsuppressed and the individual was switched to second-line within 90 days. Results For 9,949 individuals 24,948 VL tests were available. The majority were female (73%), median age 41 years (interquartile range 33–52), and 58% seen at rural clinics. Overall, 25% (260/1028) of individuals were managed according to guidelines: 40% (410/1028) had a follow-up VL within 180 days of their initial unsuppressed VL and 25% (260/1028) of those either re-suppressed or switched to second-line within 90 days. Female patients were more likely to have a follow-up VL done, (p = 0.015). In rural clinics rates of two consecutively unsuppressed VLs were higher than in the hospital (64% vs. 44%, p<0.001), and rural clinics were less likely to switch these patients to second-line (35% vs. 66%, p<0001). Conclusions Our data show that in a real-life setting availability of routine VL monitoring may not be exploited to its potential. A lack of timely follow-up after a first unsuppressed VL and reluctance to switch patients with confirmed virological failure, reduce the benefit of VL monitoring, i.e. in the rural clinics. Future studies will have to assess models of care which ensure that VL results are met with an action and make use of scalable innovative approaches.

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“…In a South African study in three clinics in eThekwini in KwaZulu-Natal, a VL champion was designated to focus on virologic management; following the intervention, the VL tests performed significantly increased from under 70% at the three clinics to over 80%. 15 In a study at 13 facilities in Malawi over a 6-month period, changing staff roles with a VL ‘focal person’ to oversee all VL activities improved VL testing 164% pre-intervention versus post-intervention. 16…”

Section: Discussionmentioning

confidence: 99%

Evaluation of a health system intervention to improve virological management in an antiretroviral programme at a municipal clinic in central Durban

Cloete¹,

Hampton²,

Chetty³

et al. 2019

Southern African Journal of HIV Medicine

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BackgroundWith the largest antiretroviral therapy (ART) programme globally, demand for effective HIV management is increasing in South Africa. While viral load (VL) testing is conducted, VL follow-up and management are sub-optimal.ObjectivesThe objective of this study was to address gaps in the VL cascade to improve VL testing and management.MethodsAntiretroviral therapy records were sampled for an in-depth review. The study team then reviewed individual records, focusing on ART management, virological suppression and retention. Multifaceted interventions focused on virological control, including a clinical summary chart for ART care; streamlining laboratory results receipt and management; monitoring VL suppression, flagging virological failure and missed visits for follow-up; down-referral of stable patients eligible for the chronic club system; and training of personnel and patients.ResultsPre-intervention, 78% (94/120) of eligible patients had VL tests, versus 92% (145/158) post-intervention (p = 0.0009). Pre-intervention, 59% (71/120) of patients accessed their VL results, versus 86% (136/158) post-intervention (p < 0.0001). Post-intervention, 73% (19/26) of patients eligible for ART change were appropriately managed, versus 11% (4/36) pre-intervention (p < 0.0001). Only 27% had no regimen changes (7/26) post-intervention, versus 81% (29/36) pre-intervention (p < 0.0001).ConclusionService delivery was streamlined to facilitate HIV services by focusing on VL test monitoring, protocol training and accessibility of results, thereby improving clinical management.

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Targeting the third ‘90’: introducing the viral load champion

Cited by 24 publications

References 11 publications

Non-uptake of viral load testing among people receiving HIV treatment in Gomba district, rural Uganda

Non-uptake of viral load testing among people receiving HIV treatment in Gomba district, rural Uganda

The viral load monitoring cascade in a resource-limited setting: A prospective multicentre cohort study after introduction of routine viral load monitoring in rural Lesotho

Evaluation of a health system intervention to improve virological management in an antiretroviral programme at a municipal clinic in central Durban

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