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Ondoa P, Kim AA, Boender TS, Zhang G, Kroeze S, Wiener J, Botes M, Botes E, Akanmu AS, Akanmu S, Wellington M, Siwale M, Mandaliya K, Kityo C, Labib EE, Adeyemo TA, Rinke de Wit T, Nkengasong J. Access to HIV Viral Load Testing and Antiretroviral Therapy Switch Practices: A Multicountry Prospective Cohort Study in Sub-Saharan Africa. AIDS Res Hum Retroviruses 2020; 36:918-926. [PMID: 32722958 DOI: 10.1089/aid.2020.0049] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Poor access to HIV viral load (VL) testing prevents the timely monitoring of HIV treatment adherence and efficacy. Factors enabling clinical benefits of VL testing when added to local standards of care, can inform the development of more cost-effective routine VL scale-up plans. We compared antiretroviral therapy (ART) switch practices in 13 clinics across 6 countries, with full (N = 8), phasing-in (N = 3) or no onsite access (N = 2) to VL. The analysis used data from the Pan-African Studies to Evaluate Resistance (PASER), observing virological and drug resistance outcomes among adults receiving first- or second-line ART between 2008 and 2015. Study plasma viral load (sVL) determined at baseline, every 12 months thereafter and at the time of switch served for retrospectively validating switch decisions, categorized into "necessary," "unnecessary," and "missed." Virological failure was defined as two consecutive sVL ≥1,000 HIV-RNA copies/mL. One thousand nine hundred ninety-five of the 2,420 (82.4%) study participants had continuous virological suppression during the median 30 months of follow-up. Among the 266 virological failures (11.0%), the proportion of necessary switches were similar in clinics with full (37%), phasing-in (25%), or no access (39%) to local VL testing. Documented utilization of local VL results for the switch decision was associated with higher percentage of necessary switch (87.6% vs. 67.9%). Shorter time to necessary switch was associated with higher rates of long-term virological suppression, regardless of access to local viral load. Availability of HIV VL testing capacity does not systematically result in adequate switch practices or better virological outcomes. Systems supporting sufficient test demand execution, and actual utilization of results for patient management need strengthening.
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Affiliation(s)
- Pascale Ondoa
- African Society for Laboratory Medicine, Addis Ababa, Ethiopia
- Amsterdam Institute for Global Health and Development, Academic Medical Center, Department of Global Health, University of Amsterdam, the Netherlands
| | - Andrea A. Kim
- Centers for Disease Control and Prevention, Atlanta, Georgia, USA
- Los Angeles County Public Health Department, Los Angeles, California, USA
| | - T. Sonia Boender
- Amsterdam Institute for Global Health and Development, Academic Medical Center, Department of Global Health, University of Amsterdam, the Netherlands
| | - Guoqing Zhang
- Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Stefanie Kroeze
- Amsterdam Institute for Global Health and Development, Academic Medical Center, Department of Global Health, University of Amsterdam, the Netherlands
| | - Jeffrey Wiener
- Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | | | | | | | | | | | | | | | | | | | | | - Tobias Rinke de Wit
- Amsterdam Institute for Global Health and Development, Academic Medical Center, Department of Global Health, University of Amsterdam, the Netherlands
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Ombelet S, Ronat JB, Walsh T, Yansouni CP, Cox J, Vlieghe E, Martiny D, Semret M, Vandenberg O, Jacobs J. Clinical bacteriology in low-resource settings: today's solutions. THE LANCET. INFECTIOUS DISEASES 2018. [PMID: 29519767 DOI: 10.1016/s1473-3099(18)30093-8] [Citation(s) in RCA: 112] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Low-resource settings are disproportionately burdened by infectious diseases and antimicrobial resistance. Good quality clinical bacteriology through a well functioning reference laboratory network is necessary for effective resistance control, but low-resource settings face infrastructural, technical, and behavioural challenges in the implementation of clinical bacteriology. In this Personal View, we explore what constitutes successful implementation of clinical bacteriology in low-resource settings and describe a framework for implementation that is suitable for general referral hospitals in low-income and middle-income countries with a moderate infrastructure. Most microbiological techniques and equipment are not developed for the specific needs of such settings. Pending the arrival of a new generation diagnostics for these settings, we suggest focus on improving, adapting, and implementing conventional, culture-based techniques. Priorities in low-resource settings include harmonised, quality assured, and tropicalised equipment, consumables, and techniques, and rationalised bacterial identification and testing for antimicrobial resistance. Diagnostics should be integrated into clinical care and patient management; clinically relevant specimens must be appropriately selected and prioritised. Open-access training materials and information management tools should be developed. Also important is the need for onsite validation and field adoption of diagnostics in low-resource settings, with considerable shortening of the time between development and implementation of diagnostics. We argue that the implementation of clinical bacteriology in low-resource settings improves patient management, provides valuable surveillance for local antibiotic treatment guidelines and national policies, and supports containment of antimicrobial resistance and the prevention and control of hospital-acquired infections.
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Affiliation(s)
- Sien Ombelet
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium; Department of Microbiology and Immunology, KU Leuven, Leuven, Belgium.
| | | | | | - Cedric P Yansouni
- JD MacLean Centre for Tropical Diseases, McGill University Health Centre, Montreal, QC, Canada
| | - Janneke Cox
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | - Erika Vlieghe
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium; Department of General Internal Medicine, Infectious and Tropical Diseases, Antwerp University Hospital, Antwerp, Belgium; Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Delphine Martiny
- Department of Microbiology, LHUB-ULB, Pôle Hospitalier Universitaire de Bruxelles, Brussels, Belgium
| | - Makeda Semret
- JD MacLean Centre for Tropical Diseases, McGill University Health Centre, Montreal, QC, Canada; St Mary's Hospital Centre, Montreal, QC, Canada
| | - Olivier Vandenberg
- Department of Microbiology, LHUB-ULB, Pôle Hospitalier Universitaire de Bruxelles, Brussels, Belgium; Center for Environmental Health and Occupational Health, Public Health School, Université Libre de Bruxelles, Brussels, Belgium
| | - Jan Jacobs
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium; Department of Microbiology and Immunology, KU Leuven, Leuven, Belgium
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Barbé B, Yansouni CP, Affolabi D, Jacobs J. Implementation of quality management for clinical bacteriology in low-resource settings. Clin Microbiol Infect 2017; 23:426-433. [PMID: 28506781 DOI: 10.1016/j.cmi.2017.05.007] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Revised: 04/28/2017] [Accepted: 05/07/2017] [Indexed: 11/25/2022]
Abstract
BACKGROUND The declining trend of malaria and the recent prioritization of containment of antimicrobial resistance have created a momentum to implement clinical bacteriology in low-resource settings. Successful implementation relies on guidance by a quality management system (QMS). Over the past decade international initiatives were launched towards implementation of QMS in HIV/AIDS, tuberculosis and malaria. AIMS To describe the progress towards accreditation of medical laboratories and to identify the challenges and best practices for implementation of QMS in clinical bacteriology in low-resource settings. SOURCES Published literature, online reports and websites related to the implementation of laboratory QMS, accreditation of medical laboratories and initiatives for containment of antimicrobial resistance. CONTENT Apart from the limitations of infrastructure, equipment, consumables and staff, QMS are challenged with the complexity of clinical bacteriology and the healthcare context in low-resource settings (small-scale laboratories, attitudes and perception of staff, absence of laboratory information systems). Likewise, most international initiatives addressing laboratory health strengthening have focused on public health and outbreak management rather than on hospital based patient care. Best practices to implement quality-assured clinical bacteriology in low-resource settings include alignment with national regulations and public health reference laboratories, participating in external quality assurance programmes, support from the hospital's management, starting with attainable projects, conducting error review and daily bench-side supervision, looking for locally adapted solutions, stimulating ownership and extending existing training programmes to clinical bacteriology. IMPLICATIONS The implementation of QMS in clinical bacteriology in hospital settings will ultimately boost a culture of quality to all sectors of healthcare in low-resource settings.
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Affiliation(s)
- B Barbé
- Institute of Tropical Medicine, Antwerp, Belgium.
| | - C P Yansouni
- JD MacLean Centre for Tropical Diseases, McGill University Health Centre, Montreal, Canada
| | - D Affolabi
- Clinical Microbiology, University Hospital Hubert Koutoukou Maga, Cotonou, Benin
| | - J Jacobs
- Institute of Tropical Medicine, Antwerp, Belgium; Department of Microbiology and Immunology, KU Leuven, Leuven, Belgium
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Tuijn CJ, Msoka E, Mushi DL, Boer MSD, Chilongola J, van den Broek A. The interface between clinicians and laboratory staff: A field study in northern Tanzania. Afr J Lab Med 2014; 3:126. [PMID: 29043178 PMCID: PMC5637763 DOI: 10.4102/ajlm.v3i1.126] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2013] [Accepted: 02/25/2014] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Strengthening the communication and professional relationships between clinicians and laboratory workers is essential in order to positively change clinicians' attitudes about the reliability of diagnostic tests, enhancing the use of laboratory diagnostics and, ultimately, improving patient care. We developed an analytical framework to gain insight into the factors that influence communication amongst health professionals. OBJECTIVE To explore whether the interaction between clinicians and laboratory workers influences the use of laboratory test results in clinical decision making. METHODS Four health facilities in northern Tanzania were selected using convenience sampling, whereas study participants were selected using purposive sampling. The quantitative and qualitative data collection methods included self-administered questionnaires; semi-structured, individual interviews; in-depth, individual interviews; and/or focus group discussions with clinicians and laboratory workers. Thematic content analyses were performed on qualitative data based on the framework. Descriptive statistical analyses of quantitative data were conducted using Microsoft Excel. RESULTS Contact between clinicians and laboratory professionals is seldom institutionalised and collaboration is rare. The clinicians believe collaboration with laboratory staff is a challenge because of the gap in education levels. Laboratory workers' education levels are often lower than their positions require, leading to clinicians' lack of respect for and confidence in laboratory professionals, which compromises the laboratory staff's motivation. CONCLUSIONS Hospital managers, clinicians and laboratory workers need to recognise the critical and complementary roles each professional plays and the importance of addressing the gap between them. Field application of the framework proved successful, justifying the expansion of this study to a larger geographical area to include additional healthcare institutions.
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Affiliation(s)
- Coosje J Tuijn
- Royal Tropical Institute (KIT) Biomedical Research, Amsterdam, the Netherlands
| | - Elizabeth Msoka
- Kilimanjaro Clinical Research Institute (KCRI), Moshi, Tanzania
| | - Declare L Mushi
- Kilimanjaro Christian Medical University College, Tumaini University Makumira, Moshi, Tanzania
| | | | - Jaffu Chilongola
- Kilimanjaro Clinical Research Institute (KCRI), Moshi, Tanzania.,Kilimanjaro Christian Medical University College, Tumaini University Makumira, Moshi, Tanzania
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