Abstract
BackgroundHIV continues to be the main determinant morbidity with high mortality rates in Sub-Saharan Africa, with a high number of patients being late presenters with advanced HIV. Clinical management of advanced HIV patients is thus complex and requires strict adherence to updated, empirical and simplified guidelines. The current study investigated the impact of the implementation of a new clinical guideline on the management of advanced HIV in Kinshasa, Democratic Republic of Congo (DRC).MethodsA retrospective analysis of routine clinical data of advanced HIV patients was conducted for the periods; February 2016 to March 2017, before implementation of new guidelines, and November 2017 to July 2018, after the implementation of new guidelines. Eligible patients were patients with CD4 < 200 cell/μl and presenting with at least 1 of 4 opportunistic infections. Patient files were reviewed by a medical doctor and a committee of 3 other doctors for congruence. Statistical significance was set at 0.05%.ResultsTwo hundred four and Two hundred thirty-one patients were eligible for inclusion before and after the implementation of new guidelines respectively. Sex and age distributions were similar for both periods, and median CD4 were 36 & 52 cell/μl, before and after the new guidelines implementation, respectively. 40.7% of patients had at least 1 missed/incorrect diagnosis before the new guidelines compared to 30% after new guidelines, p < 0.05. Clinical diagnosis for TB and toxoplasmosis were also much improved after the implementation of new guidelines. In addition, only 63% of patients had CD4 count test results before the new guidelines compared to 99% of patients after new guidelines. Death odds after the implementation of new guidelines were significantly lower than before new guidelines in a multivariate regression model that included patients CD4 count and 10 other covariates, p < 0.05.ConclusionsSimplification and implementation of a new and improved HIV clinical guideline coupled with the installation of laboratory equipment and point of care tests potentially helped reduce incorrect diagnosis and improve clinical outcomes of patients with advanced HIV. Regulating authorities should consider developing simplified versions of guidelines followed by the provision of basic diagnostic equipment to health centers.
Highlights
Human immunodeficiency virus (HIV) continues to be the main determinant morbidity with high mortality rates in Sub-Saharan Africa, with a high number of patients being late presenters with advanced HIV
Mortality rates are still unacceptably high and most low-resourced countries are yet to meet targets set by the Joint United Nations Programme on HIV/Acquired immunodeficiency syndrome (AIDS) (UNAIDS) back in 2014 [1]. .Compounding the problem is the fact that many patients still present late rendering the treatment of opportunistic infections (OIs) such as tuberculosis (TB), cryptococcal meningitis, Pneumocystis pneumonia (PCP) and non-TB pneumonia clinically complex [2]
While generic guidelines have proven to be generally effective in the management of advanced HIV, reports and studies have shown that clinicians- especially those in resource limited settings- usually struggle to effectively incorporate guidelines into their everyday practice [4]
Summary
HIV continues to be the main determinant morbidity with high mortality rates in Sub-Saharan Africa, with a high number of patients being late presenters with advanced HIV. In low HIV prevalence and low resource settings, most departments and agencies usually rely on the use of external clinical guides and algorithms for the management of HIV patients with OIs [9]. The use of these guidelines usually present a host of issues including mismatch between competencies of clinicians and proposed algorithms, lack of recommended resources, and complexity of language and/or presentation [3]. As new guidelines are introduced, it is necessary for a review of those guidelines against previous guidelines to assess and measure their effectiveness and limitations in the real world clinical setting
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