Abstract
IntroductionAccess to CD4+ testing remains a common barrier to early initiation of antiretroviral therapy among persons living with HIV/AIDS in low- and middle-income countries. The feasibility of task-shifting of point-of-care (POC) CD4+ testing to lay health workers in Namibia has not been evaluated.MethodsFrom July to August 2011, Pima CD4+ analysers were used to improve access to CD4+ testing at 10 selected public health facilities in Namibia. POC Pima CD4+ testing was performed by nurses or lay health workers. Venous blood samples were collected from 10% of patients and sent to centralised laboratories for CD4+ testing with standard methods. Outcomes for POC Pima CD4+ testing and patient receipt of results were compared between nurses and lay health workers and between the POC method and standard laboratory CD4+ testing methods.ResultsOverall, 1429 patients received a Pima CD4+ test; 500 (35.0%) tests were performed by nurses and 929 (65.0%) were performed by lay health workers. When Pima CD4+ testing was performed by a nurse or a lay health worker, 93.2% and 95.2% of results were valid (p = 0.1); 95.6% and 98.1% of results were received by the patient (p = 0.007); 96.2% and 94.0% of results were received by the patient on the same day (p = 0.08). Overall, 97.2% of Pima CD4+ results were received by patients, compared to 55.4% of standard laboratory CD4+ results (p < 0.001).ConclusionsPOC CD4+ testing was feasible and effective when task-shifted to lay health workers. Rollout of POC CD4+ testing via task-shifting can improve access to CD4+ testing and retention in care between HIV diagnosis and antiretroviral therapy initiation in low- and middle-income countries.
Highlights
Access to CD4+ testing remains a common barrier to early initiation of antiretroviral therapy among persons living with HIV/AIDS in low- and middle-income countries
In 2012, United Nations Programme on HIV/AIDS (UNAIDS) reported that only about 8 million of the 15 million people in low- and middle-income countries (LMIC) in need of antiretroviral therapy (ART) were receiving ART by the end of 2011.1 In the LMIC of sub-Saharan Africa, many barriers exist to early initiation of ART among eligible HIV-positive patients
When compared to the 59% median for the percentage of patients who were retained between HIV diagnosis and receipt of CD4+ test results in Rosen and Fox’s systematic review,[8] our results indicate that retention between HIV diagnosis and receipt of CD4+ results could be greatly improved by task-shifting POC CD4+ testing to nurses and lay health workers
Summary
Access to CD4+ testing remains a common barrier to early initiation of antiretroviral therapy among persons living with HIV/AIDS in low- and middle-income countries. In 2012, United Nations Programme on HIV/AIDS (UNAIDS) reported that only about 8 million of the 15 million people in low- and middle-income countries (LMIC) in need of antiretroviral therapy (ART) were receiving ART by the end of 2011.1 In the LMIC of sub-Saharan Africa, many barriers exist to early initiation of ART among eligible HIV-positive patients Of these barriers, limited access to CD4+ testing for determination of ART eligibility is one of the most common.[2,3,4,5,6,7] A recent systematic review of 28 published studies examining the retention of patients in sub-Saharan Africa in HIV care between testing and treatment found that the median proportion of patients retained between HIV diagnosis and receipt of CD4+ test results was 59% (range: 35% – 88%).[8]. The Pima® POC CD4+ analyser (Alere) has been validated in the field against standardof-care, laboratory-based platforms[10,11,12,13] and was listed as a World Health Organization (WHO) prequalified diagnostic in November 2011.14 Recent field-based studies in Mozambique and South Africa demonstrated that POC testing with the Pima CD4+ enabled clinics to rapidly stage patients on-site after enrolment into care, which reduced opportunities for pre-treatment loss to follow-up.[15,16] POC CD4 testing has been successfully deployed in mobile, community-based and household settings in South Africa.[17,18]
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