In Practice

A nurse-led intervention to improve management of virological failure in public sector HIV clinics in Durban, South Africa: A pre- and post-implementation evaluation

H Sunpath, S Pillay, T Hatlen, R A Murphy, V C Marconi, M-Y S Moosa, K Naidoo, M J Siedner

Abstract


Background. Identification of patients on antiretroviral therapy (ART) with virological failure (VF) and the response in the public health sector remain significant challenges. We previously reported improvement in routine viral load (VL) monitoring after ART commencement through a health system-strengthening, nurse-led ‘VL champion’ programme as part of a multidisciplinary team in three public sector clinics in Durban, South Africa.

Objectives. To report on the impact of the VL champion model adapted to identify, support and co-ordinate the management of individuals with VF on first-line ART in a setting with limited electronic-based record capacity.

Methods. We evaluated the VL champion model using a controlled before-after study design. A paper-based tool, the ‘high VL register’, was piloted under the supervision of the VL champion to improve data management, monitoring of counselling support, and enacting of clinical decisions. We abstracted chart and electronic data (TIER.net) for eligible individuals with VF in the year before and after implementation of the programme, and compared outcomes for individuals during these periods. Our primary outcome was successful completion of the VF pathway, defined as a repeat VL <1 000 copies/mL or a change to second-line ART within 6 months of VF. In a secondary analysis, we assessed the completion of each step in the pathway.

Results. We identified 60 and 56 individuals in the pre-intervention and post-intervention periods, respectively, with VF who met the inclusion criteria. Sociodemographic and clinical characteristics were similar between the periods. Repeat VL testing was completed in 61.7% and 57.8% of individuals in these two groups, respectively. We found no difference in the proportion achieving our primary outcome in the pre- and post-intervention periods: 11/60 (18.3%; 95% confidence interval (CI) 9 - 28) and 15/56 (22.8%; 95% CI 15 - 38), respectively (p=0.28). In multivariable logistic regression models adjusted for potential confounding factors, individuals in the post-intervention period had a non-significant doubling of the odds of achieving the primary outcome (adjusted odds ratio 2.07; 95% CI 0.75 - 5.72). However, there was no difference in the rates of completion of each step along the first-line VF cascade of care.

Conclusions. This enhanced intervention to improve VF in the public sector using a paper-based data management system failed to achieve significant improvements in first-line VF management over the standard of care. In addition to interventions that better address patient-centred factors that contribute to VF, we believe that there are substantial limitations to and staffing requirements involved in the ongoing utilisation of a paper-based tool. A prioritisation is needed to further expand and upgrade the electronic medical record system with capabilities for prompting staff regarding patients with missed visits and critical laboratory results demonstrating VF.


Authors' affiliations

H Sunpath, Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, South Africa; Department of Infectious Diseases, Nelson R Mandela School of Medicine, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa

S Pillay, Department of Infectious Diseases, Nelson R Mandela School of Medicine, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa

T Hatlen, Division of HIV, Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, Calif., USA

R A Murphy, Division of Infectious Diseases, Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, Calif., USA

V C Marconi, Emory University School of Medicine and Rollins School of Public Health, Atlanta, Ga., USA; Emory University Vaccine Center, Atlanta, Ga., USA; Atlanta Veterans Affairs Medical Center, Decatur, Ga., USA

M-Y S Moosa, Department of Infectious Diseases, Nelson R Mandela School of Medicine, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa

K Naidoo, Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, South Africa; Emory University Vaccine Center, Atlanta, Ga., USA; Medical Research Council-Centre for the AIDS Programme of Research in South Africa (CAPRISA) HIV-TB Pathogenesis and Treatment Research Unit, Doris Duke Medical Research Institute, University of KwaZulu-Natal, Durban, South Africa

M J Siedner, Department of Infectious Diseases, Nelson R Mandela School of Medicine, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa; Africa Health Research Institute, KwaZulu-Natal, South Africa; Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Mass., USA; Harvard Medical School, Boston, Mass., USA

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Keywords

First-line antiretroviral virological failure; HIV; Viral load champion; South Africa

Cite this article

South African Medical Journal 2021;111(4):299-303. DOI:10.7196/SAMJ.2021.v111i4.15432

Article History

Date submitted: 2021-03-31
Date published: 2021-03-31

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