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Sunpath H, Hatlen TJ, Moosa MYS, Murphy RA, Siedner M, Naidoo K. Urgent need to improve programmatic management of patients with HIV failing first-line antiretroviral therapy. Public Health Action 2020; 10:163-168. [PMID: 33437682 DOI: 10.5588/pha.20.0052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 11/04/2020] [Indexed: 11/10/2022] Open
Abstract
Introduction Delayed identification and response to virologic failure in case of first-line antiretroviral therapy (ART) in resource-limited settings is a threat to the health of HIV-infected patients. There is a need for the implementation of an effective, standardized response pathway in the public sector. Discussion We evaluated published cohorts describing virologic failure on first-line ART. We focused on gaps in the detection and management of treatment failure, and posited ways to close these gaps, keeping in mind scalability and standardization. Specific shortcomings repeatedly recorded included early loss to follow-up (>20%) after recognized first-line ART virologic failure; frequent delays in confirmatory viral load testing; and excessive time between the confirmation of first-line ART failure and initiation of second-line ART, which exceeded 1 year in some cases. Strategies emphasizing patient tracing, resistance testing, drug concentration monitoring, adherence interventions, and streamlined response pathways for those failing therapy are further discussed. Conclusion Comprehensive, evidence-based, clinical operational plans must be devised based on findings from existing research and further tested through implementation science research. Until this standard of evidence is available and implemented, high rates of losses from delays in appropriate switch to second-line ART will remain unacceptably common and a threat to the success of global HIV treatment programs.
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Affiliation(s)
- H Sunpath
- Centre for AIDS Program of Research, University of KwaZulu-Natal, Durban.,Infectious Diseases Unit, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - T J Hatlen
- Division of HIV, Lundquist Institute for Biomedical Innovation at Harbor-University of California Los Angeles Medical Center, Torrance, CA
| | - M-Y S Moosa
- Infectious Diseases Unit, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - R A Murphy
- Division of Infectious Diseases, Lundquist Institute for Biomedical Innovation at Harbor-University of California Los Angeles Medical Center, Torrance, CA
| | - M Siedner
- Massachusetts General Hospital, Boston, MA, USA
| | - K Naidoo
- Centre for AIDS Program of Research, University of KwaZulu-Natal, Durban.,HIV-TB Pathogenesis and Treatment Research Unit, Medical Research Council-Centre for the AIDS Programme of Research in South Africa, Doris Duke Medical Research Institute, University of KwaZulu-Natal, Durban, South Africa
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Sunpath H, Hatlen TJ, Naidu KK, Msimango P, Adams RN, Moosa MYS, Marconi VC, Murphy RA, Gandhi RT, Pillay S, Siedner M, Naidoo K. Targeting the third '90': introducing the viral load champion. Public Health Action 2018; 8:225-231. [PMID: 30775284 DOI: 10.5588/pha.18.0063] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2018] [Accepted: 11/05/2018] [Indexed: 11/10/2022] Open
Abstract
Objective: To move closer to achieving the third target of the UNAIDS 90-90-90 goals, we prospectively implemented a viral load (VL) champion (VLC) program aimed at enhancing VL monitoring and recognition of treatment failure. Design: Three clinics in eThekwini, Kwa-Zulu Natal (low-, medium- and high-volume, encompassing 9184 patients overall) were each assigned a VLC. We employed a descriptive analysis (chart audit) to compare the pre-intervention period to a 1-year post-intervention period. The number of patients with a VL test performed 6 and 12 months after the intervention was calculated as a proportion of VL tests due at those time points (VL completion rate). Results: The pre-implementation VL completion rate at the three sites was respectively 68% (140/205 patients), 54% (84/155 patients) and 64% (323/504 patients), and the 6-month post-implementation completion rate increased to 83% (995/1194 patients), 90% (793/878 patients) and 99% (3101/3124 patients) (P < 0.0001 for each site). VL completion rates remained significantly higher at 12 months post-implementation, with an average cumulative VL completion rate of >90% across all facilities. Conclusion: We demonstrate a successful, multifaceted, quality-improvement intervention centered on a clinic-level VLC which, taken to scale, has important implications for attaining the third UNAIDS 90-90-90 target.
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Affiliation(s)
- H Sunpath
- Centre for Aids Program of Research, University of Kwa Zulu-Natal, Durban, South Africa.,Infectious Diseases Unit, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - T J Hatlen
- Division of Infectious Diseases, Los Angeles Biomedical Research Institute, Harbor-UCLA Medical Center, Torrance, California, USA
| | - K K Naidu
- MatCH (Maternal Adolescent and Child Health), School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - P Msimango
- Ethekwini Health District Office, Department of Health, Kwa-Zulu Natal, Durban, South Africa
| | - R N Adams
- Medical Research Council-CAPRISA HIV-TB Pathogenesis and Treatment Research Unit, Doris Duke Medical Research Institute, University of KwaZulu-Natal, Durban, South Africa
| | - M-Y S Moosa
- Infectious Diseases Unit, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - V C Marconi
- Emory University School of Medicine and Rollins School of Public Health, Atlanta, Georgia, USA
| | - R A Murphy
- Division of Infectious Diseases, Los Angeles Biomedical Research Institute, Harbor-UCLA Medical Center, Torrance, California, USA
| | - R T Gandhi
- Harvard Medical School, Boston, Massachusetts, USA
| | - S Pillay
- Division of Medical Microbiology and Immunology, National Health Laboratory Services Tygerberg Hospital, Stellenbosch University, Tygerberg, South Africa
| | - M Siedner
- Massachusetts General Hospital, Boston, Massachusetts, USA
| | - K Naidoo
- Centre for Aids Program of Research, University of Kwa Zulu-Natal, Durban, South Africa.,Medical Research Council-CAPRISA HIV-TB Pathogenesis and Treatment Research Unit, Doris Duke Medical Research Institute, University of KwaZulu-Natal, Durban, South Africa
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Affiliation(s)
- M. Siedner
- Medicine, Massachusetts General Hospital, Boston, Massachusetts,
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Abstract
High-output left ventricular failure occurred in a patient after a difficult case of hysteroscopic lysis of adhesions using dextran as a distension medium. The excessive dissection in the uterine wall, the long duration of the operation, and the large volumes of dextran probably caused intravasation of dextran into the systemic circulation inducing a significant shift of fluids from the third space. This was possibly assisted by the large volume of fluids given intravenously in a 45-kg patient initiating the reported sequence of events.
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Affiliation(s)
- A Golan
- Department of Obstetrics and Gynecology, Assaf Harofeh Medical Center, Sackler School of Medicine, Tel Aviv University, Israel
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