Scale-up of Kenya’s national HIV viral load program: Findings and lessons learned

Mwau, Matilu; Syeunda, Catherine Akinyi; Adhiambo, Maureen; Bwana, Priska; Kithinji, Lucy; Mwende, Joy; Oyiengo, Laura; Sirengo, Martin; Boeke, Caroline E.

doi:10.1371/journal.pone.0190659

Cited by 63 publications

(70 citation statements)

References 25 publications

(18 reference statements)

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“…Our follow‐up testing rate among suspected failures (83%) was similar to recent findings in Lesotho (85%) and notably higher than rates reported previously in Swaziland (70%), Malawi (30%), Mozambique (35%) or Siaya County, Kenya (35%), . Notably, less than one‐third of suspect failures had a suppressed VL at their first follow‐up test, likely corresponding to high levels of acquired first‐line drug resistance in this mature cohort where VL‐monitoring was only recently introduced, as reported in similar settings . Access to routine VL‐testing, more frequent testing and a simple algorithm seem key to reducing treatment failure rates.…”

Section: Discussionsupporting

confidence: 87%

“…Notably, a recent clinical trial reported higher rates of retention, VL-suppression and referral to decentralized care in patients who received POC-VL-testing [66]. Yet, our findings (and others [17,50,53,54,56]) indicate that providing access to the technology is not enough. Regular staff training, mentoring and VL "focal-points" who monitor testing protocols are recommended.…”

Section: Discussioncontrasting

confidence: 69%

“…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.…”

Section: Discussionmentioning

confidence: 99%

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

Nicholas¹,

Poulet²,

Wolters³

et al. 2019

J Intern AIDS Soc

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Introduction Routinely monitoring the HIV viral load ( VL ) of people living with HIV ( PLHIV ) on anti‐retroviral therapy ( ART ) facilitates intensive adherence counselling and faster ART regimen switch when treatment failure is indicated. Yet standard VL ‐testing in centralized laboratories can be time‐intensive and logistically difficult in low‐resource settings. This paper evaluates the outcomes of the first four years of routine VL ‐monitoring using Point‐of‐Care technology, implemented by Médecins Sans Frontières ( MSF ) in rural clinics in Malawi. Methods We conducted a retrospective cohort analysis of patients eligible for routine VL ‐ testing between 2013 and 2017 in four decentralized ART ‐clinics and the district hospital in Chiradzulu, Malawi. We assessed VL ‐testing coverage and the treatment failure cascade (from suspected failure (first VL >1000 copies/ mL ) to VL suppression post regimen switch). We used descriptive statistics and multivariate logistic regression to assess factors associated with suspected failure. Results and Discussion Among 21,400 eligible patients, VL ‐testing coverage was 85% and VL suppression was found in 89% of those tested. In the decentralized clinics, 88% of test results were reviewed on the same day as blood collection, whereas in the district hospital the median turnaround‐time for results was 85 days. Among first‐line ART patients with suspected failure (N = 1544), 30% suppressed ( VL <1000 copies/ mL ), 35% were treatment failures (confirmed by subsequent VL ‐testing) and 35% had incomplete VL follow‐up. Among treatment failures, 80% (N = 540) were switched to a second‐line regimen, with a higher switching rate in the decentralized clinics than in the district hospital (86% vs. 67%, p < 0.01) and a shorter median time‐to‐switch (6.8 months vs. 9.7 months, p < 0.01). Similarly, the post‐switch VL ‐testing rate was markedly higher in the decentralized clinics (61% vs. 26%, p < 0.01). Overall, 79% of patients with a post‐switch VL ‐test were suppressed. Conclusions Viral load testing at the point‐of‐care in Chiradzulu, Malawi achieved high coverage and good drug regimen switch rates among those identified as treatment failures. In...

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Section: Discussionsupporting

confidence: 87%

Section: Discussioncontrasting

confidence: 69%

Section: Discussionmentioning

confidence: 99%

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

Nicholas¹,

Poulet²,

Wolters³

et al. 2019

J Intern AIDS Soc

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“…Achieving viral suppression for children in sub‐Saharan Africa is especially challenging. Studies have reported lower viral suppression rates for children and adolescents compared to adults in Kenya (57% to 66% vs. 63% to 87%) and in other low‐ and middle‐income countries (60% to 75% vs. 85%), as well as compared to children and adolescents in high‐income countries (≥ 90%) . A range of factors can influence adherence and viral suppression for children including the child's age, familial and socio‐economic environment, stigma, disclosure, and the physical and mental health status of children and caregivers .…”

Section: Discussionmentioning

confidence: 99%

Viral suppression among children and their caregivers living with HIV in western Kenya

et al. 2019

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Introduction Despite the central role of caregivers in managing HIV treatment for children living with HIV , viral suppression within caregiver–child dyads in which both members are living with HIV is not well described. Methods We conducted a retrospective analysis of children living with HIV <15 years of age and their caregivers living with HIV attending HIV clinics affiliated with the Academic Model Providing Access to Healthcare ( AMPATH ) in Kenya between 2015 and 2017. To be included in the analysis, children and caregivers must have had ≥1 viral load ( VL ) during the study period while receiving antiretroviral therapy ( ART ) for ≥6 months, and the date of the caregiver's VL must have occurred ±90 days from the date of the child's VL . The characteristics of children, caregivers and dyads were descriptively summarized. Multivariable logistic regression was used to estimate the odds of viral non‐suppression (≥ 1000 copies/ mL ) in children, adjusting for caregiver and child characteristics. Results Of 7667 children who received care at AMPATH during the study period, 1698 were linked to a caregiver living with HIV and included as caregiver–child dyads. For caregivers, 94% were mothers, median age at ART initiation 32.8 years, median CD 4 count at ART initiation 164 cells/mm 3 and 23% were not virally suppressed. For children, 52% were female, median age at ART initiation 4.2 years, median CD 4 values at ART initiation were 15% (age < 5 years) and 396 cells/mm 3 (age ≥ 5 years), and 38% were not virally suppressed. In the multivariable model, children were found more likely to not be virally suppressed if their caregivers were not suppressed compared to children with suppressed caregivers ( aOR = 2.40, 95% CI : 1.86 to 3.10). Other characteristics associated with child viral non‐suppression included caregiver ART regimen change prior to the VL , caregiver receipt of a non‐ NNRTI ‐based regimen at the time of the VL , younger child age at ART initiation and child tuberculosis treatment at the time of the VL . Conclusions Children were at higher risk of viral non‐suppression if their caregive...

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“…Finally, the online VL database is a national laboratory database that serves as the primary source for all VL test results [7].…”

Section: Data Sourcesmentioning

confidence: 99%

Monitoring the transition to new antiretroviral treatment regimens through an enhanced data system in Kenya

et al. 2020

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Background While the scale-up of HIV services has improved national health management information systems (HMIS), there remain challenges in using routine data to guide the introduction of optimized antiretroviral (ARV) drugs. Methods Building on the recent enhancements to the HMIS in Kenya and coinciding with the introduction of a new ARV regimen, tenofovir+lamivudine+dolutegravir (TLD), we developed and implemented an enhanced data system (EDS) to improve availability of safety and efficacy data among people living with HIV (PLHIV) in Kenya. Using data from one health facility, we showcase how the EDS can be used to monitor ARV transition and identify missed opportunities to transition eligible patients to optimized regimes. Results The EDS was designed to create a comprehensive PLHIV database by triangulating patient-level data from the EMR, the pharmacy ARV dispensing tool (ADT) and HIV viral load (VL) databases. On a monthly basis, the database is de-identified and uploaded into a national data warehouse, with interactive dashboards. Using the EDS, we determined that of the 5,500 PLHIV �15 years on first-line ART at one facility, 4,233 (77%) had transitioned to optimized ARVs. Of the 1,267 still on legacy regimens, 459 (36%) were determined to be eligible and prioritized to switch.

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Scale-up of Kenya’s national HIV viral load program: Findings and lessons learned

Cited by 63 publications

References 25 publications

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

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

Viral suppression among children and their caregivers living with HIV in western Kenya

Monitoring the transition to new antiretroviral treatment regimens through an enhanced data system in Kenya

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