Abstract
Objective To describe the clinical decisions taken for patients failing on treatment and possible implementation leakages within the monitoring cascade at a large urban HIV Centre in Kampala, Uganda. Methods As per internal clinic guidelines, VL results >1,000 copies/ml are flagged by a quality assurance officer and sent to the requesting clinician. The clinician fills a “decision form” choosing: (1) refer for adherence counselling, (2) repeat VL after 3 months, and (3) switch to second line. We performed data extraction on a random sample of 100 patients with VL test >1,000 copies/ml between January and August 2015. For each patient, we described the action taken by the clinicians. Results Of 6,438 patients with VL performed, 1,021 (16%) had >1,000 copies/ml. Of the 100 (10.1%) clinical files sampled, 61% were female, median age was 39 years (IQR: 32–47), 81% were on 1st-line ART, 19% on 2nd-line, median CD4 count was 249 cells/µL (IQR: 145–390), median log10 VL 4.42 (IQR: 3.98–4.92). Doctors' decisions were; refer for adherence counseling 49%, repeat VL for 25%, and switch to second line for 24% patients. Forty-one percent were not managed according to the guidelines. Of these, 29 (70.7%) were still active in care, 7 were tracked [5 (12.2%) lost to program, 2 (4.9%) dead] and 5 patients were not tracked. Conclusion Despite the implementation of internal systems to manage patients failing ART, we found substantial leakages in the monitoring “cascade”. Additional measures and stronger clinical supervision are needed to make every test count, and to ensure appropriate management of patients failing on ART.
Highlights
Remarkable progress has been made in the scale-up of antiretroviral therapy (ART) in low and middle-income countries (LMICs)
In order for HIV treatment to be effective in restoring immune-functionality, ART should control viral replication and patients should achieve viral suppression. erefore, periodic viral load (VL) testing is considered the gold standard approach for ART monitoring in HIV positive patients and in countries where VL testing is available. e most common cause for not achieving viral suppression is poor adherence, suboptimal drug concentrations due to malabsorption or drug–drug interaction, and transmitted drug resistance can contribute to viral replication [3]
Centralized VL testing commenced at the Central Public Health Laboratory (CPHL) and routine VL testing was adopted into the National ART program [4]
Summary
Remarkable progress has been made in the scale-up of antiretroviral therapy (ART) in low and middle-income countries (LMICs). In order for HIV treatment to be effective in restoring immune-functionality, ART should control viral replication and patients should achieve viral suppression. Erefore, periodic viral load (VL) testing is considered the gold standard approach for ART monitoring in HIV positive patients and in countries where VL testing is available. In the 2013 consolidated ART guidelines [4], WHO recommends monitoring ART efficacy using viral load (VL) testing performed at six months following initiation, and annually a erwards. For patients with VL >1,000 copies/ml, intensified adherence counselling (IAC) is recommended. Patients receive monthly adherence counselling sessions for three months followed by a confirmatory viral load testing at 3–6 months a er completion of IAC cycles
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