South African healthcare workers' knowledge of dolutegravir's drug-drug interactions in the first year of its rollout: a cross-sectional online survey

A retrospective study: Can dual ART mitigate the risk of potential drug-drug interactions among PLWH under stable ART?

Background/aim

People living with human immunodeficiency virus (PLWH) are getting older. Age-related comorbidities in PLWH result in polypharmacy and increase the risk for potential drug-drug interactions (pDDIs). This study aimed to evaluate how the rate of pDDIs would change if the treatment of patients receiving different combined antiretroviral therapies (ARTs) were theoretically changed with dolutegravir/lamivudine (DTG+3TC) or cabotegravir/rilpivirine (CAB+RPV).

Materials and methods

This study was conducted at the infectious disease outpatient clinic of a university hospital as a follow-up of a previous study. The data of PLWH receiving at least 1 comedication other than antiretrovirals (ARVs) were retrospectively reviewed and analyzed. The Drugs.com/Drug Interactions Checker and University of Liverpool HIV Drug Interactions Checker databases were used to identify pDDIs and their severities.

Results

A total of 75 PLWH, of whom 83% were male, with a mean age (± standard deviation) of 46.5 (±12.98) years were included. Polypharmacy was observed in 59 (79%) of the participants; however, with dual ARV options, the probability of polypharmacy was 35 (47%) (p < 0.001). In the Drugs.com database, no significant difference was found in terms of pDDIs between the treatment of current ARTs (64%) and DTG/3TC (%44) (p = 0.06) or CAB/RPV (%64) (p = 0.521). However, in the University of Liverpool database, the current rate of pDDIs (55%) was significantly higher compared to the theoretical treatment of DTG/3TC (40%) (p = 0.029), oral CAB/RPV (48%) (p = 0.003), and injectable CAB/RPV (31%) use (p = 0.006).

Conclusion

The results suggest that dual treatment regimens can reduce pDDIs, resulting in better tolerance and probably higher quality of life among PLWH.

Knowledge and Perceptions of Healthcare Workers about the Implementation of the Universal Test and Treat Guideline in Under-Resourced, High-HIV Prevalence Rural Settings

Background: South Africa (SA) began implementing its Universal Test and Treat (UTT) policy in September 2016 and Same Day Initiation (SDI) in 2017, aiming to meet the UNAIDS 90-90-90 targets by 2020. With significant advances in HIV testing, large gaps remain in the linkage and retention in care. As part of a contribution to the successful implementation of UTT, this study aims to examine progress in the implementation of the UTT and to identify gaps and facilitators in the successful implementation of the guidelines from the perspective of healthcare providers from under-resourced, high-HIV prevalence rural settings. Methods: We conducted a census of all 170 professional nurses from 18 primary healthcare (PHC) clinics in Rustenburg, South Africa, between October 2018 and February 2019. The perceptions, knowledge and attitudes of nursing staff associated with UTT implementation were investigated though the dissemination of self-administered questionnaires. Stata 16.0 was used to analyse the data. Frequency and contingency tables were used to present categorical data. The precision of the estimates was measured using a 95% confidence interval (95% CI), and the p-value of statistical significance is p < 0.05. Results: The facilities were found to have adequate governance and supervision, but gaps were identified, including staffing challenges, bottlenecks and under-resourced service delivery platforms. It was found that a high level of knowledge is a predictor of positive perception of the UTT programme and its implementation. Being supported by capacity development and having positive perceptions of UTT were important motivators for UTT implementation. Conclusions: This study was able to identify potential facilitators of the UTT strategy implementation at the selected facilities. Clinical guidelines and policies on UTT contributed to successful implementation, which means that the process of closing the gaps identified should prioritise the delivery, support and prioritisation of capacity development, infrastructure and the provision of clinical guidelines to all healthcare workers. It is recommended that nurses receive training on UTT and its benefits to increase their knowledge and promote its successful implementation in clinics.

Training, guideline access and knowledge of antiretroviral interactions: Is the South African private sector being left behind?

BACKGROUND

South Africa (SA) has the largest antiretroviral therapy programme in the world. While the majority of the country accesses healthcare in the public sector, 15.2% access private healthcare. In 2019, dolutegravir was introduced as first-line treatment for HIV. Dolutegravir has clinically significant interactions with numerous commonly used medicines, e.g. rifampicin and cation-containing medicines such as calcium and iron. They require dosage adjustments, detailed in public and private HIV guidelines.

OBJECTIVES

To describe SA healthcare workers' guideline access, training and knowledge of dolutegravir's interactions, focusing on differences between the public and private sectors.

METHODS

A cross-sectional, descriptive study was done using an online survey of healthcare workers in the field of HIV in SA, conducted by the National HIV and TB Healthcare Worker Hotline. Convenience sampling was used, with electronic dissemination to users of the hotline and by relevant HIV-focused organisations. Simple descriptive statistics and statistical analyses were used.

RESULTS

A total of 1 939 surveys were analysed, with 22% from the private sector. Training on the dolutegravir guidelines was received by significantly fewer healthcare workers in the private sector v. the public sector: 42.4% (95% confidence interval (CI) 37 - 48) v. 67.5% (95% CI I 65 - 70), respectively. Significantly fewer healthcare workers in the private sector had access to the guidelines (63.8%; 95% CI 59 - 69 v. 78.8%; 95% CI 77 - 81). When asked if they were aware that dolutegravir has interactions, just over half (56.9%) of healthcare workers in the private sector responded 'yes', 24.6% responded 'no' and 18.5% did not answer. Of those who were aware that dolutegravir has interactions, 48.9% knew that dolutegravir interacts with calcium, 44.6% with iron and 82.0% with rifampicin. Private sector knowledge of dosing changes was lower for all interacting drugs, with the difference only significant for calcium and iron. Private sector healthcare workers reported significantly lower levels of counselling on dolutegravir use in all appropriate situations.

CONCLUSION

Private sector healthcare worker access to HIV training and guidelines requires attention. In a high-burden HIV setting such as SA, it is vital that healthcare workers across all professions, in both the public and private sector, know how to adjust antiretroviral dosing due to clinically significant interactions. Without these adjustments, there is a risk of treatment failure, increased mother-to-child transmission and morbidity and mortality.