1
|
Edwards JK, Donastorg Y, Zadrozny S, Hileman S, Gómez H, Seamans MJ, Herce ME, Ramírez E, Barrington C, Weir S. A Two-stage Approach for Rapid Assessment of the Proportion Achieving Viral Suppression Using Routine Clinical Data. Epidemiology 2022; 33:642-649. [PMID: 35648416 PMCID: PMC9378579 DOI: 10.1097/ede.0000000000001513] [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] [Indexed: 11/26/2022]
Abstract
BACKGROUND Improving viral suppression among people with HIV reduces morbidity, mortality, and transmission. Accordingly, monitoring the proportion of patients with a suppressed viral load is important to optimizing HIV care and treatment programs. But viral load data are often incomplete in clinical records. We illustrate a two-stage approach to estimate the proportion of treated people with HIV who have a suppressed viral load in the Dominican Republic. METHODS Routinely collected data on viral load and patient characteristics were recorded in a national database, but 74% of patients on treatment at the time of the study did not have a recent viral load measurement. We recruited a subset of these patients for a rapid assessment that obtained additional viral load measurements. We combined results from the rapid assessment and main database using a two-stage weighting approach and compared results to estimates obtained using standard approaches to account for missing data. RESULTS Of patients with recent routinely collected viral load data, 60% had a suppressed viral load. Results were similar after applying standard approaches to account for missing data. Using the two-stage approach, we estimated that 77% (95% confidence interval [CI] = 74, 80) of those on treatment had a suppressed viral load. CONCLUSIONS When assessing the proportion of people on treatment with a suppressed viral load using routinely collected data, applying standard approaches to handle missing data may be inadequate. In these settings, augmenting routinely collected data with data collected through sampling-based approaches could allow more accurate and efficient monitoring of HIV treatment program effectiveness.
Collapse
Affiliation(s)
- Jessie K. Edwards
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Yeycy Donastorg
- Instituto Dermatológico y Cirugia de Piel, Santo Domingo, Dominican Republic
| | - Sabrina Zadrozny
- Frank Porter Graham Institute, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | | | - Hoisex Gómez
- Instituto Dermatológico y Cirugia de Piel, Santo Domingo, Dominican Republic
| | | | - Michael E. Herce
- School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Edwin Ramírez
- Servicio Nacional de Salud, Santo Domingo, Dominican Republic
| | - Clare Barrington
- Department of Health Behavior, University of North Carolina at Chapel Hill, Chapel Hill, NC
- Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Sharon Weir
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, NC
- Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, NC
| |
Collapse
|
2
|
Building and Sustaining Optimized Diagnostic Networks to Scale-up HIV Viral Load and Early Infant Diagnosis. J Acquir Immune Defic Syndr 2021; 84 Suppl 1:S56-S62. [PMID: 32520916 DOI: 10.1097/qai.0000000000002367] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Progress toward meeting the UNAIDS 2014 HIV treatment (90-90-90) targets has been slow in some countries because of gaps in access to HIV diagnostic tests. Emerging point-of-care (POC) molecular diagnostic technologies for HIV viral load (VL) and early infant diagnosis (EID) may help reduce diagnostic gaps. However, these technologies need to be implemented in a complementary and strategic manner with laboratory-based instruments to ensure optimization. METHOD Between May 2019 and February 2020, a systemic literature search was conducted in PubMed, the Cochrane Library, MEDLINE, conference abstracts, and other sources such as Unitaid, UNAIDS, WHO, and UNICEF websites to determine factors that would affect VL and EID scale-up. Data relevant to the search themes were reviewed for accuracy and were included. RESULTS Collaborations among countries, implementing partners, and donors have identified a set of framework for the effective use of both POC-based and laboratory-based technologies in large-scale VL and EID testing programs. These frameworks include (1) updated testing policies on the operational utility of POC and laboratory-based technologies, (2) expanded integrated testing using multidisease diagnostic platforms, (3) laboratory network mapping, (4) use of more efficient procurement and supply chain approaches such as all-inclusive pricing and reagent rental, and (5) addressing systemic issues such as test turnaround time, sample referral, data management, and quality systems. CONCLUSIONS Achieving and sustaining optimal VL and EID scale-up within tiered diagnostic networks would require better coordination among the ministries of health of countries, donors, implementing partners, diagnostic manufacturers, and strong national laboratory and clinical technical working groups.
Collapse
|
3
|
Williams J, Edgil D, Wattleworth M, Ndongmo C, Kuritsky J. The network approach to laboratory procurement and supply chain management: Addressing the system issues to enhance HIV viral load scale-up. Afr J Lab Med 2020; 9:1022. [PMID: 38361786 PMCID: PMC10867671 DOI: 10.4102/ajlm.v9i1.1022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Accepted: 05/15/2020] [Indexed: 02/17/2024] Open
Abstract
Investment in viral load scale-up in order to control the HIV epidemic and meet the Joint United Nations Programme on HIV and AIDS (UNAIDS) '90-90-90' goals has prompted the President's Emergency Plan for AIDS Relief and countries to increase their investment in viral load and infant virological testing. This has resulted in the increased procurement of molecular-based instruments, with many countries having challenges to effectively procure and place these products. In response to these challenges, the global laboratory stakeholder community has developed an informed 'network approach' to guide placement strategies. This article defines and describes the 'network approach' for laboratory procurement and supply chain management to assist countries in developing a strategic instrument procurement and placement strategy. The four key pillars of the approach should be performed in a stepwise fashion, with regular reviews. The approach is comprised of (1) laboratory network optimisation, (2) forecasting and supply planning, (3) the development of effective procurement and strategic sourcing to develop 'all-inclusive' contracts that provide transparent pricing, and the establishment of clear service and maintenance expectations and key performance indicators and (4) performance management to increase communication and planning, and promote issue resolution. Investments in the network approach will enable countries to strengthen laboratory systems and ready them for future laboratory needs. These disease-agnostic networks will be poised to improve overall national disease surveillance and assist countries in responding to disease outbreaks and other chronic diseases.
Collapse
Affiliation(s)
- Jason Williams
- Supply Chain Division, United States Agency for International Development (USAID), Crystal City, Virginia, United States
| | - Dianna Edgil
- Supply Chain Division, United States Agency for International Development (USAID), Crystal City, Virginia, United States
| | - Matthew Wattleworth
- Global Health Supply Chain Program, Procurement and Supply Management (GHSC-PSM), Arlington, Virginia, United States
| | - Clement Ndongmo
- Global Health Supply Chain Program, Procurement and Supply Management (GHSC-PSM), Arlington, Virginia, United States
| | - Joel Kuritsky
- Supply Chain Division, United States Agency for International Development (USAID), Crystal City, Virginia, United States
| |
Collapse
|
4
|
Alemnji G, Pati R, Chun H, Zeh C, Mosha F, Siberry G, Ondoa P. Clinical/Laboratory Interface Interventions to Improve Impact of Viral Load and Early Infant Diagnosis Testing Scale-Up. AIDS Res Hum Retroviruses 2020; 36:550-555. [PMID: 32070109 DOI: 10.1089/aid.2019.0266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Despite tremendous improvements in viral load (VL) monitoring and early infant diagnosis (EID) in many countries, low VL and EID testing rates and low VL suppression rates persist in specific regions and among certain subpopulations. The VL/EID cascade includes patient and provider demand creation, sample collection and transportation, laboratory testing, results transmission back to the clinic, and patient management. Gaps in communication and coordination between clinical and laboratory counterparts can lead to suboptimal outcomes, such as delay or inability to collect and transport samples to the laboratory for testing and failure of test results to reach providers and patients in an efficient, timely, and effective manner. To bridge these gaps and optimize the impact of VL/EID scale-up, we reviewed the components of the cascade and their interrelationships to identify barriers and facilitators. As part of this process, people living with HIV must be engaged in creating demand for VL/EID testing. In addition, there should be strong communication and collaboration between the clinical and laboratory teams throughout the cascade, along with joint performance review, site visits, and continuous quality improvement activities. Strengthening the clinical/laboratory interface requires innovative solutions and implementation of best practices, including the use of point-of-care diagnostics, simplified data systems, and an efficient supply chain system to minimize interface gaps.
Collapse
Affiliation(s)
- George Alemnji
- Division of Global HIV and Tuberculosis, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
- Office of the U.S. Global AIDS Coordinator and Health Diplomacy, Washington, District of Columbia, USA
| | - Rituparna Pati
- Division of Global HIV and Tuberculosis, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Helen Chun
- Division of Global HIV and Tuberculosis, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Clement Zeh
- Division of Global HIV and Tuberculosis, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Fausta Mosha
- HTH/Communicable Diseases Cluster, AFRO Inter-Country Support Team, World Health Organization, Harare, Zimbabwe
| | - George Siberry
- Division of Prevention, Care and Treatment, United States Agency for International Development, Arlington, Virginia, USA
| | - Pascale Ondoa
- African Society for Laboratory Medicine, Addis Ababa, Ethiopia
| |
Collapse
|
5
|
Sandbulte M, Brown M, Wexler C, Maloba M, Gautney B, Goggin K, Muchoki E, Babu S, Maosa N, Finocchario-Kessler S. Maternal viral load monitoring: Coverage and clinical action at 4 Kenyan hospitals. PLoS One 2020; 15:e0232358. [PMID: 32469876 PMCID: PMC7259657 DOI: 10.1371/journal.pone.0232358] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Accepted: 04/13/2020] [Indexed: 12/13/2022] Open
Abstract
Background Kenya’s guidelines for prevention of mother-to-child transmission of HIV (PMTCT) recommend routine viral load (VL) monitoring for pregnant and breastfeeding women. Method We assessed PMTCT VL monitoring and clinical action occurring between last menstrual period (LMP) and 6 months postpartum at 4 Kenyan government hospitals. Pregnant women enrolled in the HIV Infant Tracking System from May 2016-March 2018 were included. We computed proportions who received VL testing within recommended timeframes and who received clinical action after unsuppressed VL result. Results Of 424 participants, any VL testing was documented for 305 (72%) women and repeat VL testing was documented for 79 (19%). Only 115 women (27%) received a guideline-adherent baseline VL test and 27 (6%) received a guideline-adherent baseline and repeat VL test sequence. Return of baseline and repeat VL test results to the facility was high (average 96%), but patient notification of VL results was low (36% baseline and 49% repeat). Clinical action for unsuppressed VL results was even lower: 11 of 38 (29%) unsuppressed baseline results and 2 of 14 (14%) unsuppressed repeat results triggered clinical action. Discussion Guideline-adherent VL testing and clinical intervention during PMTCT must be prioritized to improve maternal care and reduce the risk of HIV transmission to infants.
Collapse
Affiliation(s)
- Matthew Sandbulte
- Department of Family Medicine, University of Kansas Medical Center, Kansas City, KS, United States of America
| | - Melinda Brown
- Department of Family Medicine, University of Kansas Medical Center, Kansas City, KS, United States of America
| | - Catherine Wexler
- Department of Family Medicine, University of Kansas Medical Center, Kansas City, KS, United States of America
| | - May Maloba
- Global Health Innovations, Nairobi, Kenya
| | - Brad Gautney
- Global Health Innovations, Dallas, TX, United States of America
| | - Kathy Goggin
- Health Services and Outcomes Research, Children's Mercy Kansas City, Kansas City, MO, United States of America.,School of Medicine, University of Missouri-Kansas City, Kansas City, MO, United States of America
| | | | | | | | - Sarah Finocchario-Kessler
- Department of Family Medicine, University of Kansas Medical Center, Kansas City, KS, United States of America
| |
Collapse
|
6
|
Community and activists demand for tenofovir/emtricitabine or lamivudine/dolutegravir and routine viral load testing. Curr Opin HIV AIDS 2020; 14:7-12. [PMID: 30451698 DOI: 10.1097/coh.0000000000000515] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Since the beginning of the HIV epidemic, informed communities have demanded and fought for access to life-saving treatment. The last several years have seen interesting developments in this area - particularly with respect to the switch to dolutegravir (DTG)-based regimens and scale-up of routine viral load testing (RVLT), and how these directly and indirectly impact issues of treatment optimization, HIV drug resistance, and sexual and reproductive health. In this review, we present recent advances in antiretroviral treatment and monitoring in the context of how treatment education and community demand for them. RECENT FINDINGS The latest developments with DTG and RVLT highlight underlying issues for global health systems that need to be addressed - including drug surveillance, supply chain management, and comprehensive care linkages - and the importance of community engagement in such issues. SUMMARY Decisions about treatment must be grounded in informed community demand, and should exist in the context of optimal care and treatment across the entire HIV cascade. Informed advocacy is essential for people living with HIV and their communities, so that they benefit from existing and future therapeutic advances. Research is needed on the importance of community demand across the HIV treatment cascade.
Collapse
|
7
|
Glass TR, Motaboli L, Nsakala B, Lerotholi M, Vanobberghen F, Amstutz A, Lejone TI, Muhairwe J, Klimkait T, Labhardt ND. 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. PLoS One 2019; 14:e0220337. [PMID: 31461455 PMCID: PMC6713472 DOI: 10.1371/journal.pone.0220337] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2019] [Accepted: 07/12/2019] [Indexed: 11/18/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Tracy Renee Glass
- Swiss Tropical & Public Health Institute, Basel,
Switzerland
- University of Basel, Basel, Switzerland
| | - Lipontso Motaboli
- SolidarMed, Swiss Organisation for Health in Africa, Butha-Buthe,
Lesotho
| | - Bienvenu Nsakala
- SolidarMed, Swiss Organisation for Health in Africa, Butha-Buthe,
Lesotho
| | | | - Fiona Vanobberghen
- Swiss Tropical & Public Health Institute, Basel,
Switzerland
- University of Basel, Basel, Switzerland
| | - Alain Amstutz
- Swiss Tropical & Public Health Institute, Basel,
Switzerland
- University of Basel, Basel, Switzerland
- University Hospital Basel, Division of Infectious Diseases and Hospital
Epidemiology, Basel, Switzerland
| | | | - Josephine Muhairwe
- SolidarMed, Swiss Organisation for Health in Africa, Butha-Buthe,
Lesotho
| | - Thomas Klimkait
- Molecular Virology, Department of Biomedicine, University of Basel,
Basel, Switzerland
| | - Niklaus Daniel Labhardt
- Swiss Tropical & Public Health Institute, Basel,
Switzerland
- University of Basel, Basel, Switzerland
- University Hospital Basel, Division of Infectious Diseases and Hospital
Epidemiology, Basel, Switzerland
| |
Collapse
|
8
|
Point-of-Care HIV Viral Load Testing: an Essential Tool for a Sustainable Global HIV/AIDS Response. Clin Microbiol Rev 2019; 32:32/3/e00097-18. [PMID: 31092508 DOI: 10.1128/cmr.00097-18] [Citation(s) in RCA: 61] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
The global public health community has set ambitious treatment targets to end the HIV/AIDS pandemic. With the notable absence of a cure, the goal of HIV treatment is to achieve sustained suppression of an HIV viral load, which allows for immunological recovery and reduces the risk of onward HIV transmission. Monitoring HIV viral load in people living with HIV is therefore central to maintaining effective individual antiretroviral therapy as well as monitoring progress toward achieving population targets for viral suppression. The capacity for laboratory-based HIV viral load testing has increased rapidly in low- and middle-income countries, but implementation of universal viral load monitoring is still hindered by several barriers and delays. New devices for point-of-care HIV viral load testing may be used near patients to improve HIV management by reducing the turnaround time for clinical test results. The implementation of near-patient testing using these new and emerging technologies may be an essential tool for ensuring a sustainable response that will ultimately enable an end to the HIV/AIDS pandemic. In this report, we review the current and emerging technology, the evidence for decentralized viral load monitoring by non-laboratory health care workers, and the additional considerations for expanding point-of-care HIV viral load testing.
Collapse
|
9
|
Tlhajoane M, Masoka T, Mpandaguta E, Rhead R, Church K, Wringe A, Kadzura N, Arinaminpathy N, Nyamukapa C, Schur N, Mugurungi O, Skovdal M, Eaton JW, Gregson S. A longitudinal review of national HIV policy and progress made in health facility implementation in Eastern Zimbabwe. Health Res Policy Syst 2018; 16:92. [PMID: 30241489 PMCID: PMC6150955 DOI: 10.1186/s12961-018-0358-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Accepted: 08/02/2018] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND In recent years, WHO has made major changes to its guidance on the provision of HIV care and treatment services. We conducted a longitudinal study from 2013 to 2015 to establish how these changes have been translated into national policy in Zimbabwe and to measure progress in implementation within local health facilities. METHODS National HIV programme policy guidelines published between 2003 and 2013 (n = 9) and 2014 and 2015 (n = 5) were reviewed to assess adoption of WHO recommendations on HIV testing services, prevention of mother-to-child transmission (PMTCT) of HIV, and provision of antiretroviral therapy (ART). Changes in local implementation of these policies over time were measured in two rounds of a survey conducted at 36 health facilities in Eastern Zimbabwe in 2013 and 2015. RESULTS High levels of adoption of WHO guidance into national policy were recorded, including adoption of new recommendations made in 2013-2015 to introduce PMTCT Option B+ and to increase the threshold for ART initiation from CD4 ≤ 350 cells/mm3 to ≤ 500 cells/mm3. New strategies to implement national HIV policies were introduced such as the decentralisation of ART services from hospitals to clinics and task-shifting of care from doctors to nurses. The proportions of health facilities offering free HIV testing and counselling, PMTCT (including Option B+) and ART services increased substantially from 2013 to 2015, despite reductions in numbers of health workers. Provision of provider-initiated HIV testing remained consistently high. At least one test-kit stock-out in the prior year was reported in most facilities (2013: 69%; 2015: 61%; p = 0.44). Stock-outs of first-line ART and prophylactic drugs for opportunistic infections remained low. Repeat testing for HIV-negative individuals within 3 months decreased (2013: 97%; 2015: 72%; p = 0.01). Laboratory testing remained low across both survey rounds, despite policy and operational guidelines to expand coverage of diagnostic services. CONCLUSIONS Good progress has been made in implementing international guidance on HIV service delivery in Zimbabwe. Further novel implementation strategies may be needed to achieve the latest targets for universal ART eligibility.
Collapse
Affiliation(s)
- Malebogo Tlhajoane
- Department for Infectious Disease Epidemiology, Imperial College London, Norfolk Place, London, W2 1PG United Kingdom
| | - Tidings Masoka
- Biomedical Research and Training Institute, Harare, Zimbabwe
| | | | - Rebecca Rhead
- Department for Infectious Disease Epidemiology, Imperial College London, Norfolk Place, London, W2 1PG United Kingdom
| | - Kathryn Church
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Alison Wringe
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Noah Kadzura
- Biomedical Research and Training Institute, Harare, Zimbabwe
| | - Nimalan Arinaminpathy
- Department for Infectious Disease Epidemiology, Imperial College London, Norfolk Place, London, W2 1PG United Kingdom
| | - Constance Nyamukapa
- Department for Infectious Disease Epidemiology, Imperial College London, Norfolk Place, London, W2 1PG United Kingdom
- Biomedical Research and Training Institute, Harare, Zimbabwe
| | - Nadine Schur
- Department for Infectious Disease Epidemiology, Imperial College London, Norfolk Place, London, W2 1PG United Kingdom
| | | | - Morten Skovdal
- Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Jeffrey W. Eaton
- Department for Infectious Disease Epidemiology, Imperial College London, Norfolk Place, London, W2 1PG United Kingdom
| | - Simon Gregson
- Department for Infectious Disease Epidemiology, Imperial College London, Norfolk Place, London, W2 1PG United Kingdom
- Biomedical Research and Training Institute, Harare, Zimbabwe
| |
Collapse
|
10
|
Reepalu A, Balcha TT, Skogmar S, Isberg PE, Medstrand P, Björkman P. Development of an algorithm for determination of the likelihood of virological failure in HIV-positive adults receiving antiretroviral therapy in decentralized care. Glob Health Action 2018; 10:1371961. [PMID: 28914169 PMCID: PMC5645660 DOI: 10.1080/16549716.2017.1371961] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Background: Early identification of virological failure (VF) limits occurrence and spread of drug-resistant viruses in patients receiving antiretroviral treatment (ART). Viral load (VL) monitoring is therefore recommended, but capacities to comply with this are insufficient in many low-income countries. Clinical algorithms might identify persons at higher likelihood of VF to allocate VL resources. Objectives: We aimed to construct a VF algorithm (the Viral Load Testing Criteria; VLTC) and compare its performance to the 2013 WHO treatment failure criteria. Methods: Subjects with VL results available 1 year after ART start (n = 494) were identified from a cohort of ART-naïve adults (n = 812), prospectively recruited and followed 2011–2015 at Ethiopian health centres. VF was defined as VL≥1000 copies/mL. Variables recorded at the time of sampling, with potential association with VF, were used to construct the algorithm based on multivariate logistic regression. Results: Fifty-seven individuals (12%) had VF, which was independently associated with CD4 count <350 cells/mm3, previous ART interruption, and short mid-upper arm circumference (<24cm and <23cm, for men and women, respectively). These variables were included in the VLTC. In derivation, the VLTC identified 52/57 with VF; sensitivity 91%, specificity 43%, positive predictive value (PPV) 17%, negative predictive value (NPV) 97%. In comparison, the WHO criteria identified 38/57 with VF (sensitivity 67%, specificity 74%, PPV 25%, NPV 94%). Conclusions: The VLTC identified subjects at greater likelihood of VF, with higher sensitivity and NPV than the WHO criteria. If external validation confirms this performance, these criteria could be used to allocate limited VL resources. Due to its limited specificity, it cannot be used to determine treatment failure in the absence of a confirmatory viral load.
Collapse
Affiliation(s)
- Anton Reepalu
- a Clinical Infection Medicine, Department of Translational Medicine , Lund University , Malmö , Sweden
| | - Taye Tolera Balcha
- a Clinical Infection Medicine, Department of Translational Medicine , Lund University , Malmö , Sweden.,b Armauer Hansen Research Institute , Addis Ababa , Ethiopia
| | - Sten Skogmar
- a Clinical Infection Medicine, Department of Translational Medicine , Lund University , Malmö , Sweden
| | - Per-Erik Isberg
- c Department of Statistics , Lund University , Lund , Sweden
| | - Patrik Medstrand
- d Clinical Virology, Department of Translational Medicine , Lund University , Malmö , Sweden
| | - Per Björkman
- a Clinical Infection Medicine, Department of Translational Medicine , Lund University , Malmö , Sweden
| |
Collapse
|
11
|
Peter T, Zeh C, Katz Z, Elbireer A, Alemayehu B, Vojnov L, Costa A, Doi N, Jani I. Scaling up HIV viral load - lessons from the large-scale implementation of HIV early infant diagnosis and CD4 testing. J Int AIDS Soc 2018; 20 Suppl 7. [PMID: 29130601 PMCID: PMC5978645 DOI: 10.1002/jia2.25008] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Accepted: 08/21/2017] [Indexed: 01/09/2023] Open
Abstract
INTRODUCTION The scale-up of effective HIV viral load (VL) testing is an urgent public health priority. Implementation of testing is supported by the availability of accurate, nucleic acid based laboratory and point-of-care (POC) VL technologies and strong WHO guidance recommending routine testing to identify treatment failure. However, test implementation faces challenges related to the developing health systems in many low-resource countries. The purpose of this commentary is to review the challenges and solutions from the large-scale implementation of other diagnostic tests, namely nucleic-acid based early infant HIV diagnosis (EID) and CD4 testing, and identify key lessons to inform the scale-up of VL. DISCUSSION Experience with EID and CD4 testing provides many key lessons to inform VL implementation and may enable more effective and rapid scale-up. The primary lessons from earlier implementation efforts are to strengthen linkage to clinical care after testing, and to improve the efficiency of testing. Opportunities to improve linkage include data systems to support the follow-up of patients through the cascade of care and test delivery, rapid sample referral networks, and POC tests. Opportunities to increase testing efficiency include improvements to procurement and supply chain practices, well connected tiered laboratory networks with rational deployment of test capacity across different levels of health services, routine resource mapping and mobilization to ensure adequate resources for testing programs, and improved operational and quality management of testing services. If applied to VL testing programs, these approaches could help improve the impact of VL on ART failure management and patient outcomes, reduce overall costs and help ensure the sustainable access to reduced pricing for test commodities, as well as improve supportive health systems such as efficient, and more rigorous quality assurance. These lessons draw from traditional laboratory practices as well as fields such as logistics, operations management and business. CONCLUSIONS The lessons and innovations from large-scale EID and CD4 programs described here can be adapted to inform more effective scale-up approaches for VL. They demonstrate that an integrated approach to health system strengthening focusing on key levers for test access such as data systems, supply efficiencies and network management. They also highlight the challenges with implementation and the need for more innovative approaches and effective partnerships to achieve equitable and cost-effective test access.
Collapse
Affiliation(s)
- Trevor Peter
- Clinton Health Access Initiative, Gaborone, Botswana
| | - Clement Zeh
- United States Centers for Disease Control, Addis Ababa, Ethiopia
| | - Zachary Katz
- Foundation for Innovative New Diagnostics, Geneva, Switzerland
| | - Ali Elbireer
- African Society for Laboratory Medicine, Addid Ababa, Ethiopia
| | | | - Lara Vojnov
- World Health Organization, Geneva, Switzerland
| | | | - Naoko Doi
- Clinton Health Access Initiative, Gaborone, Botswana
| | - Ilesh Jani
- Institut Nacional Da Saude, Maputo, Mozambique
| |
Collapse
|
12
|
Alemnji G, Chase M, Branch S, Guevara G, Nkengasong J, Albalak R. Improving Laboratory Efficiency in the Caribbean to Attain the World Health Organization HIV Treat All Recommendations. AIDS Res Hum Retroviruses 2018; 34:132-139. [PMID: 28967269 DOI: 10.1089/aid.2017.0158] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Scientific evidence showing the benefits of early initiation of antiretroviral therapy (ART) prompted World Health organization (WHO) to recommend that all persons diagnosed as HIV positive should commence ART irrespective of CD4 count and disease progression. Based on this recommendation, countries should adopt and implement the HIV "Treat All" policy to achieve the UNAIDS 90-90-90 targets and ultimately reach epidemic control. Attaining this goal along the HIV treatment cascade depends on the laboratory to monitor progress and measure impact. The laboratory plays an important role in HIV diagnosis to attain the first 90 and in viral load (VL) and HIV drug resistance testing to reinforce adherence, improve viral suppression, and measure the third 90. Countries in the Caribbean region have endorsed the WHO HIV "Treat all" recommendation; however, they are faced with diminishing financial resources to support laboratory testing, seen as a rate-limiting factor to achieving this goal. To improve laboratory coverage with fewer resources in the Caribbean there is the need to optimize laboratory operations to ensure the implementation of high quality, less expensive evidence-based approaches that will result in more efficient and effective service delivery. Suggested practical and innovative approaches to achieve this include: (1) targeted testing within HIV hotspots; (2) strengthening sample referral systems for VL; (3) better laboratory data collection systems; and (4) use of treatment cascade data for programmatic decision-making. Furthermore, strengthening quality improvement and procurement systems will minimize diagnostic errors and guarantee a continuum of uninterrupted testing which is critical for routine monitoring of patients to meet the stated goal.
Collapse
Affiliation(s)
- George Alemnji
- Division of Global HIV and Tuberculosis, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia
- State Department Office of the Global AIDS Coordinator and Health Diplomacy (S/GAC), Washington, District of Columbia
| | - Martine Chase
- Caribbean Regional Office, Division of Global HIV/AIDS, Centers for Disease Control and Prevention (CDC), US Embassy, Bridgetown, Barbados
| | - Songee Branch
- Ladymeade Reference Unit Laboratory, Ministry of Health, Bridgetown, Barbados
| | - Giselle Guevara
- Caribbean Regional Office, Division of Global HIV/AIDS, Centers for Disease Control and Prevention (CDC), US Embassy, Bridgetown, Barbados
| | - John Nkengasong
- Division of Global HIV and Tuberculosis, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia
| | - Rachel Albalak
- Caribbean Regional Office, Division of Global HIV/AIDS, Centers for Disease Control and Prevention (CDC), US Embassy, Bridgetown, Barbados
| |
Collapse
|
13
|
Use of expenditure analysis to enhance returns on investments in HIV services. Curr Opin HIV AIDS 2017. [PMID: 28639989 DOI: 10.1097/coh.0000000000000395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Globally, the response to the HIV epidemic is at a crisis point. International investments in the HIV response have been essentially flat for 8 years and domestic budgets in low and middle-income countries - still recovering from the global recession - have not been able to fill the resource gap to drive a full-fledged HIV response. Still, efficiencies and prioritization of evidence-based interventions enable a significant scale-up of treatment, but millions more people remain without treatment. This review looks at recent data and research to evaluate interventions that may help close gaps in service provision that undermine testing and treatment programs. RECENT FINDINGS The President's Emergency Plan for AIDS Relief recently began publicly releasing vast programmatic and expenditure data. These data reveal potential efficiency gaps in testing and treatment programs, particularly in the area of linkage and retention. Interventions such as HIV self-testing have been proposed to help, but whether they can deliver better results remains unclear. Same-day initiation on treatment improves initiation, retention, and viral suppression rates. SUMMARY Near real-time analysis of data and active response is critical in improving efficiencies in programs. More investment in implementation research is necessary to improve linkage to care and treatment to reach 90-90-90 goals.
Collapse
|