Impact and Programmatic Implications of Routine Viral Load Monitoring in Swaziland

Jobanputra, Kiran; Parker, Lucy Anne; Azih, Charles; Okello, Velephi; Maphalala, Gugu; Jouquet, Guillaume; Kerschberger, Bernhard; Mekeidje, Calorine; Cyr, Joanne; Mafikudze, Arnold; Han, Win Min; Lujan, Johnny; Teck, Roger; Antierens, Annick; Griensven, Johan van; Reid, Tony

doi:10.1097/qai.0000000000000224

Cited by 49 publications

(63 citation statements)

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“…To our knowledge, only one other study has reported on VL outcomes of a PMTCTB+ cohort in sub-Saharan Africa and reported similar findings [37]. VL monitoring was still quite a novel practice for health workers and its routine use for treatment monitoring was still not fully established [38]. In addition, according to our data, women were often lost to follow-up before they became eligible to receive their first VL at 6 months after ART initiation.…”

Section: Discussionmentioning

confidence: 89%

Challenges and successes in the implementation of option B+ to prevent mother-to-child transmission of HIV in southern Swaziland

et al. 2018

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BackgroundUniversal antiretroviral therapy (ART) for all pregnant/ breastfeeding women living with Human Immunodeficiency Virus (HIV), known as Prevention of mother-to child transmission of HIV (PMTCT) Option B+ (PMTCTB+), is being scaled up in most countries in Sub-Saharan Africa. In the transition to PMTCTB+, many countries face challenges with proper implementation of the HIV care cascade. We aimed to describe the feasibility of a PMTCTB+ approach in the public health sector in Swaziland.MethodsLifelong ART was offered to a cohort of HIV+ pregnant women aged ≥16 years at the first antenatal care (ANC1) visit in 9 public sector facilities, between 01/2013 and 06/2014. The study enrolment period was divided into 3 phases (early: 01–06/2013, mid: 07–12/2013 and late: 01–06/2014) to account for temporal trends. Kaplan-Meier estimates and Cox proportional-hazards regression models were applied for ART initiation and attrition analyses.ResultsOf 665 HIV+ pregnant women, 496 (74.6%) initiated ART. ART initiation increased in later study enrolment phases (mid: aHR: 1.41; later: aHR: 2.36), and decreased at CD4 ≥ 500 (aHR: 0.69). 52.9% were retained in care at 24 months. Attrition was associated with ANC1 in the third trimester (aHR: 2.37), attending a secondary care facility (aHR: 1.98) and ART initiation during later enrolment phases (mid aHR: 1.48; late aHR: 1.67). Of 373 women eligible, 67.3% received a first VL. 223/251 (88.8%) were virologically suppressed (< 1000 copies/mL). Of 670 infants, 53.6% received an EID test, 320/359 had a test result recorded and of whom 7 (2.2%) were HIV+.ConclusionsPMTCTB+ was found to be feasible in this setting, with high rates of maternal viral suppression and low transmission to the infant. High treatment attrition, poor follow-up of mother-baby pairs and under-utilisation of VL and EID testing are important programmatic challenges.

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Section: Discussionmentioning

confidence: 89%

Challenges and successes in the implementation of option B+ to prevent mother-to-child transmission of HIV in southern Swaziland

et al. 2018

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“…VL measured at 12 month intervals for 48 monthsNot statedNo time point specific provided for % patient with VL data available. Scheduled clinic visit 6 monthly at tertiary hospitalJanssen, 2010 [21]6–12 months447193/447 (43.2%)CD4%: 310/447 (69.3%); CD4: 315/447 (70.5%)NRLaboratory tests (CD4, VL, Hemoglobin/albumin) repeated 6 monthlyVL testing at referral hospital (75 km away); other tests at local hospitalJobanputra, 2014 [26]12 months55634767/5563 (86%)NRNRVL measured annually using a Generic HIV VL platform (Biocentric)VL testing at regional virology laboratoryMutevedzi, 2010 [20]12 months2527/3010758/2527 (30%)NRNRCD4 count and VL measured every 6 monthsVL testing at provincial labVL measured by Nucli-Sens Easy HIV-1 assay). Type of blood used not reportRich, 2012 [22]24 months926275/926 (29.7%)710/926 (76.7%)NRCD4 count measured 6 monthly using BD fluorescence-activated cell sorting count systemNot statedSelke, 2010 [14]12 monthsIntervention: 87Control: 102Intervention: 86/87 (99%)Control: 96/102 (94.1%)Intervention: 87/87 (100%)Control: 96/102 (94.1%)Intervention: 74/87 (85%)Control: 87/102 (85.3%)VL and CD4 count obtained at initial and close out research visit.…”

Section: Resultsmentioning

confidence: 99%

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

et al. 2017

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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...

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“…Observations from rural HIV clinics in various resource-limited countries have shown that inadequately managed HIV treatment and care programmes may result in high levels of virological failure and widespread drug resistance. 26,27 To date, only a few Tanzanian studies have investigated the virological effectiveness of ART and the emergence of HIV-DRM among ART-experienced HIV patients, typically under stavudine-based Ntamatungiro et al…”

Section: Discussionmentioning

confidence: 99%

Strengthening HIV therapy and care in rural Tanzania affects rates of viral suppression

Ntamatungiro

Muri

Glass

et al. 2017

Journal of Antimicrobial Chemotherapy

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Impact and Programmatic Implications of Routine Viral Load Monitoring in Swaziland

Abstract: Supplemental Digital Content is Available in the Text.

Cited by 49 publications

References 12 publications

Challenges and successes in the implementation of option B+ to prevent mother-to-child transmission of HIV in southern Swaziland

Challenges and successes in the implementation of option B+ to prevent mother-to-child transmission of HIV in southern Swaziland

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

Strengthening HIV therapy and care in rural Tanzania affects rates of viral suppression

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