Feasibility of antiretroviral treatment monitoring in the era of decentralized HIV care: a systematic review

Abstract

BackgroundRegular monitoring of HIV patients who are receiving antiretroviral therapy (ART) is required to ensure patient benefits and the long-term effectiveness and sustainability of ART programs. Prompted by WHO recommendations for expansion and decentralization of HIV treatment and care in low and middle income countries, we conducted a systematic review to assess the feasibility of treatment monitoring in these settings.MethodsA comprehensive search strategy was developed using a combination of MeSH and free text terms relevant to HIV treatment and care, health service delivery, health service accessibility, decentralization and other relevant terms. Five electronic databases and two conference websites were searched to identify relevant studies conducted in LMICs, published in English between Jan 2006 and Dec 2015. Outcomes of interest included the proportion of patients who received treatment monitoring and health system factors related to monitoring of patients on ART under decentralized HIV service delivery models.ResultsFrom 5363 records retrieved, twenty studies were included in the review; all but one was conducted in sub-Saharan African countries. The majority of studies (15/20) had relatively short follow-up duration (≤24 months), and only two studies were specifically designed to assess treatment monitoring practices. The most frequently studied follow-up period was 12 months and a wide range of treatment monitoring coverage was observed. The reported proportions of patients on ART who received CD4 monitoring ranged from very low (6%; N = 2145) to very high (95%; N = 488). The median uptake of viral load monitoring was 86% with studies in program settings reporting coverage as low as 14%. Overall, the longer the follow-up period, the lower the proportion of patients who received regular monitoring tests; and programs in rural areas reported low coverage of laboratory monitoring. Moreover, uptake in the context of research had significantly better where monitoring was done by dedicated research staff. In the absence of point of care (POC) testing, the limited capacity for blood sample transportation between clinic and laboratory and poor quality of nursing staff were identified as a major barrier for treatment monitoring practice.ConclusionsThere is a paucity of data on the uptake of treatment monitoring, particularly with longer-term follow-up. Wide variation in access to both virological and immunological regular monitoring was observed, with some clinics in well-resourced settings supported by external donors achieving high coverage. The feasibility of treatment monitoring, particularly in decentralized settings of HIV treatment and care may thus be of concern and requires further study. Significant investment in POC diagnostic technologies and, improving the quality of and training for nursing staff is required to ensure effective scale up of ART programs towards the targets of 90-90-90 by the year 2020.Electronic supplementary materialThe online version of this article (doi:10.1186/s12981-017-0...

Implementation of “Treat‐all” at adult HIV care and treatment sites in the Global IeDEA Consortium: results from the Site Assessment Survey

“…While almost all sites reported universal HIV treatment as the standard of care, we found considerable variation in site‐level practices related to rapid ART initiation, with private sector sites and sites in high‐resource settings more likely to report longer times to treatment initiation. Consistent with other research , we also found considerable variation in capacity for viral load monitoring, and almost one‐third of the sites implementing Treat All indicated that they could not routinely request or perform viral load testing. Such gaps were particularly prevalent among sites located in rural areas and in low‐income countries, as well as in countries where Treat All was adopted more recently.…”

Point‐of‐care viral load monitoring: outcomes from a decentralized HIV programme in Malawi

“…Monitoring systems with performance indicators should be implemented, ideally with integrated, automated systems that identify patients in need of VL-testing [67]. Creating demand for VL among clinicians and patients will be critical [20,21,35,56,[68][69][70][71]. A recent modelling study predicted that switching patients on efavirenz-based first-line after only one high VL will significantly decrease mortality related to delayed switch [72], POC-VL and same day results would further support this concept.…”

“…Knowing their VL status can motivate patients to adhere to treatment [9,10], and can allocate virally suppressed patients into differentiated models of care [11,12]. Yet despite being associated with better treatment outcomes and the prevention of acquired drug resistance [6,13], routine VL-monitoring remains under-utilized in resource-limited settings [14][15][16][17][18][19][20][21]. It was estimated that less than 50% of people on ART in resource-limited settings received an annual VL test in 2017 [22].The test's cost and complexity remain barriers to its use, as does a lack of understanding by some clinicians about VL's long-term patient benefits and its role in prolonging the longevity of treatment regimens [18,21].…”

“…Centralized testing with dried blood spots (DBS), is a practical and efficient VL-testing method, with the drawback of often lengthy result turnaround-time (TAT) [23][24][25][26][27]. Point-of-Care (POC)-technology offers an attractive alternative that provides same-day results for clinical decisions by bringing testing directly to the facility [16,[18][19][20]24,[28][29][30][31][32][33]. Today, several POC-VL technologies are in the pipeline or are becoming more accessible for low-resource settings [34].…”

Microbiome and Probiotics inHealth and HIV Infection

“…The intestinal microbiota of HIV patients appears to contain higher levels of pathogens, such as Pseudomonas aeruginosa and Candida albicans and reduced levels of LAB species. Thus, gut reconditioning through probiotic administration could be protective for the gut surface and delay the progression to AIDS [93,94] (Figure 3). In young HIV infected subjects, elevated inflammation levels, persistent immune activation and dysfunction will be observed for many years.…”