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Giang JH, Basha G, Thomas KK, Oyaro P, Chohan BH, Kingwara L, Hassan SA, Yongo N, Wagude J, Oluoch F, Odhiambo F, Oyaro B, John-Stewart GC, Abuogi LL, Patel RC. Real-world performance of point-of-care vs. standard-of-care HIV viral load testing in western Kenya: Secondary analysis of Opt4Kids and Opt4Mamas studies. PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0003378. [PMID: 38913630 PMCID: PMC11195974 DOI: 10.1371/journal.pgph.0003378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 05/30/2024] [Indexed: 06/26/2024]
Abstract
Routine HIV viral load testing is important for evaluating HIV treatment outcomes, but conventional viral load testing has many barriers including expensive laboratory equipment and lengthy results return times to patients. A point-of-care viral load testing technology, such as GeneXpert HIV-1 quantification assay, could reduce these barriers by decreasing cost and turnaround time, however real-world performance is limited. We conducted a secondary analysis using 900 samples collected from participants in two studies to examine the performance of GeneXpert as point-of-care viral load compared to standard-of-care testing (which was conducted with two centralized laboratories using traditional HIV-1 RNA PCR quantification assays). The two studies, Opt4Kids (n = 704 participants) and Opt4Mamas (n = 820 participants), were conducted in western Kenya from 2019-2021 to evaluate the effectiveness of a combined intervention strategy, which included point-of-care viral load testing. Paired viral load results were compared using four different thresholds for virological non-suppression, namely ≥50, ≥200, ≥400, ≥1000 copies/ml. At a threshold of ≥1000 copies/mL, paired samples collected on the same day: demonstrated sensitivities of 90.0% (95% confidence interval [CI] 68.3, 98.8) and 66.7% (9.4, 99.2), specificities of 98.4% (95.5, 99.7) and 100% (96.5, 100), and percent agreements of 97.7% (94.6, 99.2) and 99.1% (95.0, 100) in Opt4Kids and Opt4Mamas studies, respectively. When lower viral load thresholds were used and the paired samples were collected an increasing number of days apart, sensitivity, specificity, and percent agreement generally decreased. While specificity and percent agreement were uniformly high, sensitivity was lower than expected. Non-specificity of the standard of care testing may have been responsible for the sensitivity values. Nonetheless, our results demonstrate that GeneXpert may be used reliably to monitor HIV treatment in low- and middle- income countries to attain UNAID's 95-95-95 HIV goals.
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Affiliation(s)
- Jessica H. Giang
- School of Medicine, University of Washington, Seattle, Washington, United States of America
| | - Garoma Basha
- Department of Medicine, University of Washington, Seattle, Washington, United States of America
| | - Katherine K. Thomas
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
| | | | - Bhavna H. Chohan
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
| | - Leonard Kingwara
- National HIV Reference Laboratory, Kenya Ministry of Health, Nairobi, Kenya
| | - Shukri A. Hassan
- Department of Medicine, University of Washington, Seattle, Washington, United States of America
| | | | | | | | - Francesca Odhiambo
- Family AIDS Care and Education Services, Kenya Medical Research Institute, Kisumu, Kenya
| | - Boaz Oyaro
- Kenya Medical Research Institute-CDC, Kisian, Kenya
| | - Grace C. John-Stewart
- Department of Medicine, University of Washington, Seattle, Washington, United States of America
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
- Departments of Pediatrics and Epidemiology, University of Washington, Seattle, Washington, United States of America
| | - Lisa L. Abuogi
- Department of Pediatrics, University of Colorado, Denver, Colorado, United States of America
| | - Rena C. Patel
- Department of Medicine, University of Washington, Seattle, Washington, United States of America
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
- Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, United States of America
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Gavina K, Franco LC, Khan H, Lavik JP, Relich RF. Molecular point-of-care devices for the diagnosis of infectious diseases in resource-limited settings - A review of the current landscape, technical challenges, and clinical impact. J Clin Virol 2023; 169:105613. [PMID: 37866094 DOI: 10.1016/j.jcv.2023.105613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 10/17/2023] [Indexed: 10/24/2023]
Abstract
Molecular point-of-care (POC) tests offer high sensitivity, rapid turnaround times, relative ease of use, and the convenience of laboratory-grade testing in the absence of formal laboratory spaces and equipment, making them appealing options for infectious disease diagnosis in resource-limited settings. In this review, we discuss the role and potential of molecular POC tests in resource-limited settings and their associated logistical challenges. We discuss U.S. Food and Drug Administration approval, Clinical Laboratory Improvement Amendments complexity levels, and the REASSURED criteria as a starting point for assessing options currently available inside and outside of the United States. We then present POC tests currently in research and development phases that have potential for commercialization and implementation in limited-resource settings. Finally, we review published studies that have assessed the clinical impact of molecular POC testing in limited- and moderate-resource settings.
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Affiliation(s)
- Kenneth Gavina
- Department of Pathology and Laboratory Medicine, Indiana University School of Medicine, Indianapolis, IN, USA; Division of Clinical Microbiology, Indiana University Health, Indianapolis, IN, USA
| | - Lauren C Franco
- Department of Pathology and Laboratory Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Haseeba Khan
- Department of Pathology and Laboratory Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - John-Paul Lavik
- Department of Pathology and Laboratory Medicine, Indiana University School of Medicine, Indianapolis, IN, USA; Division of Clinical Microbiology, Indiana University Health, Indianapolis, IN, USA
| | - Ryan F Relich
- Department of Pathology and Laboratory Medicine, Indiana University School of Medicine, Indianapolis, IN, USA; Division of Clinical Microbiology, Indiana University Health, Indianapolis, IN, USA.
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Abuogi L, Oyaro P, Wakjira G, Thomas KK, Scallon AJ, Mukui I, Chohan BH, Brown E, Karauki E, Yongo N, Ahmed B, Hassan SA, Wagude J, Kinywa E, Otieno L, Kingwara L, Oyaro B, Frenkel LM, John-Stewart G, Patel RC. HIV Drug Resistance Patterns and Characteristics Associated with Clinically Significant Drug Resistance among Children with Virologic Failure on Antiretroviral Treatment in Kenya: Findings from the Opt4Kids Randomized Controlled Trial. Viruses 2023; 15:2083. [PMID: 37896860 PMCID: PMC10612029 DOI: 10.3390/v15102083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 09/29/2023] [Accepted: 10/09/2023] [Indexed: 10/29/2023] Open
Abstract
Increasing HIV drug resistance (DR) among children with HIV (CHIV) on antiretroviral treatment (ART) is concerning. CHIV ages 1-14 years enrolled from March 2019 to December 2020 from five facilities in Kisumu County, Kenya, were included. Children were randomized 1:1 to control (standard-of-care) or intervention (point-of-care viral load (POC VL) testing every three months with targeted genotypic drug resistance testing (DRT) for virologic failure (VF) (≥1000 copies/mL)). A multidisciplinary committee reviewed CHIV with DRT results and offered treatment recommendations. We describe DR mutations and present logistic regression models to identify factors associated with clinically significant DR. We enrolled 704 children in the study; the median age was 9 years (interquartile range (IQR) 7, 12), 344 (49%) were female, and the median time on ART was 5 years (IQR 3, 8). During the study period, 106 (15%) children had DRT results (84 intervention and 22 control). DRT detected mutations associated with DR in all participants tested, with 93 (88%) having major mutations, including 51 (54%) with dual-class resistance. A history of VF in the prior 2 years (adjusted odds ratio (aOR) 11.1; 95% confidence interval (CI) 6.3, 20.0) and less than 2 years on ART at enrollment (aOR 2.2; 95% CI 1.1, 4.4) were associated with increased odds of major DR. DR is highly prevalent among CHIV on ART with VF in Kenya. Factors associated with drug resistance may be used to determine which children should be prioritized for DRT.
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Affiliation(s)
- Lisa Abuogi
- Department of Pediatrics, University of Colorado, Denver, CO 80045, USA
| | - Patrick Oyaro
- Health Innovations Kenya (HIK), Kisumu 40100, Kenya;
- United States Agency for International Development, Washington, DC 20004, USA
| | - Garoma Wakjira
- Department of Medicine, University of Washington, Seattle, WA 98195, USA; (G.W.); (S.A.H.); (L.M.F.); (G.J.-S.); (R.C.P.)
| | - Katherine K. Thomas
- Department of Global Health, University of Washington, Seattle, WA 98105, USA; (K.K.T.); (A.J.S.); (B.H.C.)
| | - Andrea J. Scallon
- Department of Global Health, University of Washington, Seattle, WA 98105, USA; (K.K.T.); (A.J.S.); (B.H.C.)
| | - Irene Mukui
- Drugs for Neglected Diseases Initiative (DNDI), Nairobi 21936, Kenya;
| | - Bhavna H. Chohan
- Department of Global Health, University of Washington, Seattle, WA 98105, USA; (K.K.T.); (A.J.S.); (B.H.C.)
- Kenya Medical Research Institute, Nairobi 00200, Kenya
| | | | | | | | - Bilaal Ahmed
- Department of Pediatrics, University of Colorado, Denver, CO 80045, USA
| | - Shukri A. Hassan
- Department of Medicine, University of Washington, Seattle, WA 98195, USA; (G.W.); (S.A.H.); (L.M.F.); (G.J.-S.); (R.C.P.)
| | - James Wagude
- Department of Health, Ministry of Health, Siaya 40600, Kenya
| | - Eunice Kinywa
- Department of Health, Ministry of Health, Kisumu 40100, Kenya
| | - Linda Otieno
- Family AIDS Care and Education Services, Kenya Medical Research Institute, Kisumu 40100, Kenya
| | - Leonard Kingwara
- National HIV Reference Laboratory, Kenya Ministry of Health, Nairobi 00202, Kenya;
| | - Boaz Oyaro
- Kenya Medical Research Institute-CDC, Kisumu 40100, Kenya;
| | - Lisa M. Frenkel
- Department of Medicine, University of Washington, Seattle, WA 98195, USA; (G.W.); (S.A.H.); (L.M.F.); (G.J.-S.); (R.C.P.)
- Department of Global Health, University of Washington, Seattle, WA 98105, USA; (K.K.T.); (A.J.S.); (B.H.C.)
- Departments of Pediatrics, University of Washington, Seattle, WA 98195, USA
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, WA 98195, USA
| | - Grace John-Stewart
- Department of Medicine, University of Washington, Seattle, WA 98195, USA; (G.W.); (S.A.H.); (L.M.F.); (G.J.-S.); (R.C.P.)
- Department of Global Health, University of Washington, Seattle, WA 98105, USA; (K.K.T.); (A.J.S.); (B.H.C.)
- Departments of Pediatrics, University of Washington, Seattle, WA 98195, USA
| | - Rena C. Patel
- Department of Medicine, University of Washington, Seattle, WA 98195, USA; (G.W.); (S.A.H.); (L.M.F.); (G.J.-S.); (R.C.P.)
- Department of Global Health, University of Washington, Seattle, WA 98105, USA; (K.K.T.); (A.J.S.); (B.H.C.)
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Scallon AJ, Hassan SA, Qian SR, Gao Y, Oyaro P, Brown E, Wagude J, Mukui I, Kinywa E, Oluoch F, Odhiambo F, Oyaro B, Kingwara L, Yongo N, Karauki E, Otieno L, John-Stewart GC, Abuogi LL, Patel RC. "I feel drug resistance testing allowed us to make an informed decision": qualitative insights on the role of HIV drug resistance mutation testing among children and pregnant women living with HIV in western Kenya. BMC Health Serv Res 2023; 23:908. [PMID: 37620855 PMCID: PMC10463841 DOI: 10.1186/s12913-023-09804-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Accepted: 07/10/2023] [Indexed: 08/26/2023] Open
Abstract
BACKGROUND Pregnant women and children living with HIV in Kenya achieve viral suppression (VS) at lower rates than other adults. While many factors contribute to these low rates, the acquisition and development of HIV drug resistance mutations (DRMs) are a contributing factor. Recognizing the significance of DRMs in treatment decisions, resource-limited settings are scaling up national DRM testing programs. From provider and patient perspectives, however, optimal ways to operationalize and scale-up DRM testing in such settings remain unclear. METHODS Our mixed methods study evaluates the attitudes towards, facilitators to, and barriers to DRM testing approaches among children and pregnant women on antiretroviral therapy (ART) in five HIV treatment facilities in Kenya. We conducted 68 key informant interviews (KIIs) from December 2019 to December 2020 with adolescents, caregivers, pregnant women newly initiating ART or with a high viral load, and providers, laboratory/facility leadership, and policy makers. Our KII guides covered the following domains: (1) DRM testing experiences in routine care and through our intervention and (2) barriers and facilitators to routine and point-of-care DRM testing scale-up. We used inductive coding and thematic analysis to identify dominant themes with convergent and divergent subthemes. RESULTS The following themes emerged from our analysis: (1) DRM testing and counseling were valuable to clinical decision-making and reassuring to patients, with timely results allowing providers to change patient ART regimens faster; (2) providers and policymakers desired an amended and potentially decentralized DRM testing process that incorporates quicker sample-to-results turn-around-time, less burdensome procedures, and greater patient and provider "empowerment" to increase comfort with testing protocols; (3) facility-level delays, deriving from overworked facilities and sample tracking difficulties, were highlighted as areas for improvement. CONCLUSIONS DRM testing has the potential to considerably improve patient health outcomes. Key informants recognized several obstacles to implementation and desired a more simplified, time-efficient, and potentially decentralized DRM testing process that builds provider comfort and confidence with DRM testing protocols. Further investigating the implementation, endurance, and effectiveness of DRM testing training is critical to addressing the barriers and areas of improvement highlighted in our study. TRIAL REGISTRATION NCT03820323.
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Affiliation(s)
- Andrea J Scallon
- Jackson School of International Studies, University of Washington, Seattle, USA
| | - Shukri A Hassan
- Department of Medicine, University of Washington, 325 9th Ave, Seattle, WA, 98105, USA
| | | | - Yuandi Gao
- School of Public Health, University of Washington, Seattle, USA
| | | | | | | | - Irene Mukui
- Drugs for Neglected Diseases Initiative, Nairobi, Kenya
| | | | | | - Francesca Odhiambo
- Family AIDS Care and Education Services, Kenya Medical Research Institute, Kisumu, Kenya
| | - Boaz Oyaro
- Kenya Medical Research Institute-CDC, Kisian, Kenya
| | - Leonard Kingwara
- National HIV Reference Laboratory, Ministry of Health, Nairobi, Kenya
| | | | | | - Lindah Otieno
- Family AIDS Care and Education Services, Kenya Medical Research Institute, Kisumu, Kenya
| | - Grace C John-Stewart
- Department of Medicine, University of Washington, 325 9th Ave, Seattle, WA, 98105, USA
- Departments of Global Health, University of Washington, 325 9th Ave, WA, 98105, Seattle, USA
- Department of Pediatrics, University of Washington, Seattle, USA
- Department of Epidemiology, University of Washington, Seattle, USA
| | - Lisa L Abuogi
- Department of Pediatrics, University of Colorado, Denver, USA
| | - Rena C Patel
- Department of Medicine, University of Washington, 325 9th Ave, Seattle, WA, 98105, USA.
- Departments of Global Health, University of Washington, 325 9th Ave, WA, 98105, Seattle, USA.
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Nanyeenya N, Chang LW, Kiwanuka N, Nasuuna E, Nakanjako D, Nakigozi G, Kibira SPS, Nabadda S, Kiyaga C, Makumbi F. The association between low-level viraemia and subsequent viral non-suppression among people living with HIV/AIDS on antiretroviral therapy in Uganda. PLoS One 2023; 18:e0279479. [PMID: 36638086 PMCID: PMC9838846 DOI: 10.1371/journal.pone.0279479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 12/08/2022] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Uganda's efforts to end the HIV epidemic by 2030 are threatened by the increasing number of PLHIV with low-level viraemia (LLV). We conducted a study to determine the prevalence of LLV and the association between LLV and subsequent viral non-suppression from 2016 to 2020 among PLHIV on ART in Uganda. METHOD This was a retrospective cohort study, using the national viral load (VL) program data from 2016 to 2020. LLV was defined as a VL result of at least 50 copies/ml, but less than 1,000 copies/ml. Multivariable logistic regression was used to determine the factors associated with LLV, and cox proportional hazards regression model was used to determine the association between LLV and viral non-suppression. RESULTS A cohort of 17,783 PLHIV, of which 1,466 PLHIV (8.2%) had LLV and 16,317 (91.8%) had a non-detectable VL was retrospectively followed from 2016 to 2020. There were increasing numbers of PLHIV with LLV from 2.0% in 2016 to 8.6% in 2020; and LLV was associated with male sex, second line ART regimen and being of lower age. 32.5% of the PLHIV with LLV (476 out of 1,466 PLHIV) became non-suppressed, as compared to 7.7% of the PLHIV (1,254 out of 16,317 PLHIV) with a non-detectable viral load who became non-suppressed during the follow-up period. PLHIV with LLV had 4.1 times the hazard rate of developing viral non-suppression, as compared to PLHIV with a non-detectable VL (adjusted hazard ratio was 4.1, 95% CI: 3.7 to 4.7, p < 0.001). CONCLUSION Our study indicated that PLHIV with LLV increased from 2.0% in 2016 to 8.6% in 2020, and PLHIV with LLV had 4.1 times the hazard rate of developing viral non-suppression, as compared to PLHIV with a non-detectable VL. Hence the need to review the VL testing algorithm and also manage LLV in Uganda.
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Affiliation(s)
- Nicholus Nanyeenya
- Department of Epidemiology and Biostatistics, School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda
- Department of National Health Laboratory Services, Ministry of Health, Kampala Uganda
| | - Larry William Chang
- Department of Epidemiology, School of Medicine, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Noah Kiwanuka
- Department of Epidemiology and Biostatistics, School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - Esther Nasuuna
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - Damalie Nakanjako
- Department of Medicine, School of Medicine Makerere University College of Health Sciences, Kampala, Uganda
| | | | - Simon P. S. Kibira
- Department of Community Health and Behavioral Sciences, School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - Susan Nabadda
- Department of National Health Laboratory Services, Ministry of Health, Kampala Uganda
| | - Charles Kiyaga
- Department of National Health Laboratory Services, Ministry of Health, Kampala Uganda
| | - Fredrick Makumbi
- Department of Epidemiology and Biostatistics, School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda
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Qian SRW, Hassan SA, Scallon AJ, Oyaro P, Brown E, Wagude J, Mukui I, Kinywa E, Oluoch F, Odhiambo F, Oyaro B, Kingwara L, Yongo N, Karauki E, Gao J, Otieno L, John-Stewart GC, Abuogi LL, Patel RC. "After viral load testing, I get my results so I get to know which path my life is taking me": qualitative insights on routine centralized and point-of-care viral load testing in western Kenya from the Opt4Kids and Opt4Mamas studies. BMC Health Serv Res 2022; 22:1540. [PMID: 36528677 PMCID: PMC9758673 DOI: 10.1186/s12913-022-08593-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Accepted: 09/21/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Viral suppression (VS) is a marker of effective HIV therapy, and viral load (VL) testing is critical for treatment monitoring, especially in high-risk groups such as children and pregnant/postpartum women. Although routine VL testing, via centralized laboratory networks, was implemented in Kenya starting in 2014, optimization and sustainable scale up of VL testing are still needed. METHODS We conducted a mixed methods study to evaluate the impact of higher frequency, point-of-care (POC) VL testing in optimizing VS among children and pregnant/postpartum women on antiretroviral treatment (ART) in five HIV treatment facilities in western Kenya in the Opt4Kids and Opt4Mamas studies. We conducted 68 key informant interviews (KIIs) from December 2019 to December 2020 with children and pregnant women living with HIV, child caregivers, providers, laboratory/facility leadership, and county- or national-level policymakers. Our KII guide covered the following domains: (1) barriers and facilitators to ART use and VS, (2) literacy and experiences with VL in routine care and via study, and (3) opinions on how to scale up VL testing for optimal programmatic use. We used inductive coding and thematic analysis to identify dominant themes with convergent and divergent subthemes. RESULTS Three main themes regarding VL testing emerged from our analysis. (1) Key informants uniformly contrasted POC VL testing's faster results turnaround, higher accessibility, and likely cost-effectiveness against centralized VL testing. (2) Key informants also identified areas of improvement for POC VL testing in Kenya, such as quality control, human resource and infrastructure capacity, supply chain management, and integration of VL testing systems. (3) To enable successful scale-up of VL testing, key informants proposed expanding the POC VL testing scheme, electronic medical records systems, conducting quality checks locally, capacity building and developing strong partnerships between key stakeholders. CONCLUSION The more accessible, decentralized model of POC VL testing was deemed capable of overcoming critical challenges associated with centralized VL testing and was considered highly desirable for optimizing VS for children and pregnant/postpartum women living with HIV. While POC VL testing has the potential to improve VS rates among these populations, additional research is needed to develop strategies for ensuring the sustainability of POC VL testing programs. TRIAL REGISTRATION NCT03820323, 29/01/2019.
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Affiliation(s)
| | - Shukri A Hassan
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - Andrea J Scallon
- Jackson School of International Studies, University of Washington, Seattle, WA, USA
| | | | | | | | - Irene Mukui
- Drugs for Neglected Diseases Initiative, Nairobi, Kenya
| | | | | | - Francesca Odhiambo
- Family AIDS Care and Education Services, Kenya Medical Research Institute, Kisumu, Kenya
| | - Boaz Oyaro
- Kenya Medical Research Institute-CDC, Kisian, Kenya
| | - Leonard Kingwara
- National HIV Reference Laboratory, Kenya Ministry of Health, Nairobi, Kenya
| | | | | | - Jody Gao
- School of Public Health, University of Washington, Seattle, WA, USA
| | - Lindah Otieno
- Family AIDS Care and Education Services, Kenya Medical Research Institute, Kisumu, Kenya
| | - Grace C John-Stewart
- Department of Medicine, University of Washington, Seattle, WA, USA
- Department of Global Health, University of Washington, Seattle, WA, USA
- Department of Pediatrics, University of Washington, Seattle, WA, USA
- Department of Epidemiology, University of Washington, Seattle, WA, USA
| | - Lisa L Abuogi
- Department of Pediatrics, University of Colorado, Denver, CO, USA
| | - Rena C Patel
- Department of Medicine, University of Washington, Seattle, WA, USA.
- Department of Global Health, University of Washington, Seattle, WA, USA.
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Patel RC, Oyaro P, Thomas KK, Wagude J, Mukui I, Brown E, Hassan SA, Kinywa E, Oluoch F, Odhiambo F, Oyaro B, Kingwara L, Karauki E, Yongo N, Otieno L, John-Stewart GC, Abuogi LL. Point-of-care HIV viral load and targeted drug resistance mutation testing versus standard care for Kenyan children on antiretroviral therapy (Opt4Kids): an open-label, randomised controlled trial. THE LANCET. CHILD & ADOLESCENT HEALTH 2022; 6:681-691. [PMID: 35987208 PMCID: PMC9482947 DOI: 10.1016/s2352-4642(22)00191-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 06/10/2022] [Accepted: 06/15/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Feasible, scalable, and cost-effective approaches to ensure virological suppression among children living with HIV are urgently needed. The aim of the Opt4Kids study was to determine the effect of point of care viral load and targeted drug resistance mutation testing in improving virological suppression among children on antiretroviral therapy (ART) in Kenya. METHODS In this open-label, individually randomised controlled trial, we enrolled children living with HIV aged 1-14 years and who were either newly initiating or already receiving ART at five study facilities in Kenya. Participants were randomly allocated 1:1 to receive the intervention of point-of-care viral load testing every 3 months, targeted drug resistance mutation testing, and clinical decision support (point-of-care testing) or to receive the standard care (control group), stratified by facility site and age groups (1-9 years vs 10-14 years). Investigators were masked to the randomised group. The primary efficacy outcome was virological suppression (defined as a viral load of <1000 copies per mL) by point-of-care viral load testing at 12 months after enrolment in all participants with an assessment. This study is registered with ClinicalTrials.gov, NCT03820323. FINDINGS Between March 7, 2019, and December 31, 2020, we enrolled 704 participants. Median age at enrolment was 9 years (IQR 7-12), 344 (49%) participants were female and 360 (51%) were male, and median time on ART was 5·8 years (IQR 3·1-8·6). 536 (76%) of 704 had documented virological suppression at enrolment. At 12 months after enrolment, the proportion of participants achieving virological suppression in the intervention group (283 [90%] of 313 participants with a 12 month point-of-care viral load test) did not differ from that in the control group (289 [92%] of 315; risk ratio [RR] 0·99, 95% CI 0·94-1·03; p=0·55). We identified 138 episodes of viraemia in intervention participants, of which 107 (89%) samples successfully underwent drug resistance mutation testing and 91 (85%) had major drug resistance mutations. The median turnaround time for viral load results was 1 day (IQR 0-1) in the intervention group and 15 days (10-21) in the control group. INTERPRETATION Point-of-care viral load testing decreased turnaround time and targeted drug resistance mutation testing identified a high prevalence of HIV drug resistance mutations in children living with HIV, but the combined approach did not increase rates of virological suppression. Further research in combination interventions, including point-of-care viral load and drug resistance mutation testing coupled with psychosocial support, is needed to optimise virological suppression for children living with HIV. FUNDING National Institutes of Mental Health of the US National Institutes of Health, Thrasher Research Fund.
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Affiliation(s)
- Rena C Patel
- Department of Medicine, University of Washington, Seattle, WA, USA; Department of Global Health, University of Washington, Seattle, WA, USA.
| | | | | | | | - Irene Mukui
- Drugs for Neglected Diseases Initiative (DNDI), Nairobi, Kenya
| | | | - Shukri A Hassan
- Department of Medicine, University of Washington, Seattle, WA, USA
| | | | | | - Francesca Odhiambo
- Family AIDS Care and Education Services, Kenya Medical Research Institute, Kisumu, Kenya
| | - Boaz Oyaro
- Kenya Medical Research Institute-CDC, Kisian, Kenya
| | - Leonard Kingwara
- National HIV Reference Laboratory, Kenya Ministry of Health, Nairobi, Kenya
| | | | | | - Lindah Otieno
- Family AIDS Care and Education Services, Kenya Medical Research Institute, Kisumu, Kenya
| | - Grace C John-Stewart
- Department of Medicine, University of Washington, Seattle, WA, USA; Department of Global Health, University of Washington, Seattle, WA, USA; Departments of Pediatrics and Epidemiology, University of Washington, Seattle, WA, USA
| | - Lisa L Abuogi
- Department of Pediatrics, University of Colorado, Denver, CO, USA
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Dorward J, Sookrajh Y, Ngobese H, Lessells R, Sayed F, Bulo E, Moodley P, Samsunder N, Lewis L, Tonkin-Crine S, Drain PK, Hayward G, Butler CC, Garrett N. Protocol for a randomised feasibility study of Point-Of-care HIV viral load testing to Enhance Re-suppression in South Africa: the POwER study. BMJ Open 2021; 11:e045373. [PMID: 33593788 PMCID: PMC7888322 DOI: 10.1136/bmjopen-2020-045373] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 01/21/2021] [Accepted: 02/02/2021] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Access to HIV viral load testing remains difficult for many people on antiretroviral therapy (ART) in low-income and middle-income countries. Weak laboratory and clinic systems often delay the detection and management of viraemia, which can lead to morbidity, drug resistance and HIV transmission. Point-of-care testing could overcome these challenges. We aim to assess whether it is feasible to conduct a randomised trial of point-of-care viral load testing to manage viraemia. METHODS AND ANALYSIS We will conduct an open-label, single-site, individually randomised, feasibility study of Point-Of-care HIV viral load testing to Enhance Re-suppression, in Durban, South Africa. We will enrol approximately 100 people living with HIV who are aged ≥18 years, receiving first-line ART but with recent viraemia ≥1000 copies/mL, and randomise them 1:1 to receive point-of-care viral load or standard laboratory viral load monitoring, after 12 weeks. All participants will continue to receive care from public sector healthcare workers following South African HIV management guidelines. Participants with persistent viraemia ≥1000 copies/mL will be considered for switching to second-line ART. We will compare the proportion in each study arm who achieve the primary outcome of viral suppression <50 copies/mL at 24 weeks after enrolment. Additional outcomes include proportions retained in the study, proportions with HIV drug resistance, time to viral load results and time to switching to second-line ART. We will assess implementation of point-of-care viral load testing using process evaluation data, and through interviews and focus groups with healthcare workers. ETHICS AND DISSEMINATION University of Oxford Tropical Research Ethics Committee and the Biomedical Research Ethics Committee of the University of KwaZulu-Natal have approved the study. We will present results to stakeholders, and through conferences and open-access, peer-reviewed journals. TRIAL REGISTRATION NUMBER PACTR202001785886049.
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Affiliation(s)
- Jienchi Dorward
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
- Centre for the Aids Programme of Research in South Africa, University of KwaZulu-Natal, Durban, South Africa
| | | | - Hope Ngobese
- eThekwini Municipality Health Unit, Durban, South Africa
| | - Richard Lessells
- Centre for the Aids Programme of Research in South Africa, University of KwaZulu-Natal, Durban, South Africa
- KwaZulu-Natal Research and Innovation Sequencing Platform (KRISP), University of KwaZulu-Natal, Durban, South Africa
| | - Fathima Sayed
- Centre for the Aids Programme of Research in South Africa, University of KwaZulu-Natal, Durban, South Africa
| | - Elliot Bulo
- eThekwini Municipality Health Unit, Durban, South Africa
| | - P Moodley
- Department of Virology, University of KwaZulu-Natal, Durban, South Africa
- National Health Laboratory Service, Inkosi Albert Luthuli Central Hospital, Durban, South Africa
| | - Natasha Samsunder
- Centre for the Aids Programme of Research in South Africa, University of KwaZulu-Natal, Durban, South Africa
| | - Lara Lewis
- Centre for the Aids Programme of Research in South Africa, University of KwaZulu-Natal, Durban, South Africa
| | - Sarah Tonkin-Crine
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
- NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, University of Oxford, Oxford, UK
| | - Paul K Drain
- Department of Global Health, Schools of Medicine and Public Health, University of Washington, Seattle, Washington, USA
- Department of Medicine, School of Medicine, University of Washington, Seattle, Washington, USA
- Department of Epidemiology, School of Public Health, University of Washington, Seattle, Washington, USA
| | - Gail Hayward
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Christopher C Butler
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Nigel Garrett
- Centre for the Aids Programme of Research in South Africa, University of KwaZulu-Natal, Durban, South Africa
- Discipline of Public Health Medicine, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
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Bulterys MA, Oyaro P, Brown E, Yongo N, Karauki E, Wagude J, Kingwara L, Bowen N, Njogo S, Wagner AD, Mukui I, Oluoch F, Abuogi L, Patel R, Sharma M. Costs of Point-of-Care Viral Load Testing for Adults and Children Living with HIV in Kenya. Diagnostics (Basel) 2021; 11:140. [PMID: 33477850 PMCID: PMC7832863 DOI: 10.3390/diagnostics11010140] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 01/16/2021] [Accepted: 01/17/2021] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND The number of people living with HIV (PLHIV) in need of treatment monitoring in low-and-middle-income countries is rapidly expanding, straining existing laboratory capacity. Point-of-care viral load (POC VL) testing can alleviate the burden on centralized laboratories and enable faster delivery of results, improving clinical outcomes. However, implementation costs are uncertain and will depend on clinic testing volume. We sought to estimate the costs of decentralized POC VL testing compared to centralized laboratory testing for adults and children receiving HIV care in Kenya. METHODS We conducted microcosting to estimate the per-patient costs of POC VL testing compared to known costs of centralized laboratory testing. We completed time-and-motion observations and stakeholder interviews to assess personnel structures, staff time, equipment costs, and laboratory processes associated with POC VL administration. Capital costs were estimated using a 5 year lifespan and a 3% annual discount rate. RESULTS We estimated that POC VL testing cost USD $24.25 per test, assuming a clinic is conducting 100 VL tests per month. Test cartridge and laboratory equipment costs accounted for most of the cost (62% and 28%, respectively). Costs varied by number of VL tests conducted at the clinic, ranging from $54.93 to $18.12 per test assuming 20 to 500 VL tests per month, respectively. A VL test processed at a centralized laboratory was estimated to cost USD $25.65. CONCLUSION POC VL testing for HIV treatment monitoring can be feasibly implemented in clinics within Kenya and costs declined with higher testing volumes. Our cost estimates are useful to policymakers in planning resource allocation and can inform cost-effectiveness analyses evaluating POC VL testing.
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Affiliation(s)
- Michelle Ann Bulterys
- Departments of Epidemiology and Global Health, University of Washington, Seattle, WA 98105, USA; (P.O.); (A.D.W.); (I.M.); (R.P.); (M.S.)
| | - Patrick Oyaro
- Departments of Epidemiology and Global Health, University of Washington, Seattle, WA 98105, USA; (P.O.); (A.D.W.); (I.M.); (R.P.); (M.S.)
- Health Innovations Kenya, Kisumu, Kenya
| | - Evelyn Brown
- Department of HIV Research, University of Washington Kenya, Nairobi, Kenya; (E.B.); (N.Y.); (E.K.)
| | - Nashon Yongo
- Department of HIV Research, University of Washington Kenya, Nairobi, Kenya; (E.B.); (N.Y.); (E.K.)
| | - Enericah Karauki
- Department of HIV Research, University of Washington Kenya, Nairobi, Kenya; (E.B.); (N.Y.); (E.K.)
| | | | - Leonard Kingwara
- National HIV Reference Laboratory, National Public Health Laboratory, Nairobi, Kenya; (L.K.); (N.B.); (F.O.)
| | - Nancy Bowen
- National HIV Reference Laboratory, National Public Health Laboratory, Nairobi, Kenya; (L.K.); (N.B.); (F.O.)
| | - Susan Njogo
- National AIDS and STI Control Programme, Ministry of Health, Nairobi 19361, Kenya;
| | - Anjuli D. Wagner
- Departments of Epidemiology and Global Health, University of Washington, Seattle, WA 98105, USA; (P.O.); (A.D.W.); (I.M.); (R.P.); (M.S.)
| | - Irene Mukui
- Departments of Epidemiology and Global Health, University of Washington, Seattle, WA 98105, USA; (P.O.); (A.D.W.); (I.M.); (R.P.); (M.S.)
| | - Frederick Oluoch
- National HIV Reference Laboratory, National Public Health Laboratory, Nairobi, Kenya; (L.K.); (N.B.); (F.O.)
| | - Lisa Abuogi
- Department of Pediatrics, University of Colorado, Denver, CO 80045, USA;
| | - Rena Patel
- Departments of Epidemiology and Global Health, University of Washington, Seattle, WA 98105, USA; (P.O.); (A.D.W.); (I.M.); (R.P.); (M.S.)
- Department of Medicine, Division of Allergy and Infectious Diseases, University of Washington, Seattle, WA 98105, USA
| | - Monisha Sharma
- Departments of Epidemiology and Global Health, University of Washington, Seattle, WA 98105, USA; (P.O.); (A.D.W.); (I.M.); (R.P.); (M.S.)
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