Page 171 - SAHCS HIVMed Journal Vol 20 No 1 2019

Page 2 of 8 Original Research

proportion of viral suppression among South Africans living comprehensive clinical care such as management of
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with HIV was 23.8%. Part of the challenge of achieving communicable and non-communicable diseases. In addition,
virologic suppression may be the complexity of VL monitoring there were few opportunities for doctors to mentor nurses. The
– from attaining patient blood samples, transport of laboratory guideline also recommended down-referral of stable patients
specimens, documenting results in patients’ files and who were suppressed virologically to community-based
appropriate management of virological outcomes. 7 ‘chronic clubs’ for ongoing care.

Moreover, maintaining viral suppression may be particularly The current South African guideline recommends VL testing
challenging with psychosocial, cultural and economic following ART initiation at 6 months, 12 months and
obstacles to adherence, including efficient systems for thereafter annually. For patients with VL < 400 copies/mL,
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laboratory monitoring and adequate, timely drug supply. VL monitoring may be conducted annually, depending on
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Given the multifactorial barriers, maintaining drug adherence the ART duration and routine adherence support. If the VL
may necessitate a hierarchical approach with patients at risk > 50 copies/mL, adherence support should be intensified.
triaged for additional clinical and psychosocial support. 8 Patients with VL 400 copies/mL – 1000 copies/mL should
have their adherence carefully assessed and a repeat VL test
The primary objective of this health systems intervention was to within 6 months. Patients with VL > 1000 copies/mL should
address gaps in the VL cascade in a real-world setting to improve have their adherence assessed, intensive adherence support
VL testing and management. In this article, we present the and a repeat VL test in 2 months; if the VL remains > 1000
evaluation of results for this health system intervention. copies/mL, the patient should be switched to a second-line
ART regimen. If the repeat VL is < 1000 copies/mL, the VL
Research methods and design should be repeated in 6 months and reassessed for further
Study design management.

The study team conducted a health system intervention to
improve the quality of HIV services, focusing on virological Study population and sampling strategy
management. All patients (n = 1538) enrolled in the ART programme at the
PHC facility from 01 September 2011 to 31 March 2014 were
Setting included in pre-intervention reviews. Furthermore, the
authors systematically sampled 13% of all patients initiated
The eThekwini district of KwaZulu-Natal (KZN) had an HIV on ART between 01 September 2011 and 31 March 2014 for
prevalence of 11.4% in 2016 and one of the highest antenatal in-depth file reviews.
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HIV prevalence rates in the country at 41.1% in 2013. The
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HIV programme implemented at the Lancers Road Primary Every 10th file was selected for review and recording data
Healthcare (PHC) clinic is managed by the eThekwini Health captured until end of March 2014. In addition, files of patients
Unit, situated near a busy taxi rank in Durban. This PHC commenced on ART in the 3 months following the initial file
offered a unique opportunity to determine if a quality review period, that is, 01 April 2014–30 June 2014, were
improvement intervention could improve virological reviewed post-intervention.
management in a setting servicing a highly mobile population.
It offers standard PHC services: antenatal care, well-baby Health systems assessment
clinic and/or immunisations, HIV counselling and testing,
ART provision, tuberculosis (TB) screening and treatment and Our research involved file reviews at several time
other chronic care services to patients from the greater points: (1) pre-intervention review conducted from 01
functional region within 100 km radius. April to 30 June 2014 of patients enrolled in the ART
programme from 01 September 2011 to 31 March 2014; (2)
intervention (01 April 2014 – 31 March 2015) and (3) post-
Routine HIV management
intervention assessment (May 2015 to 31 December 2015)
Approximately 60–70 HIV-positive patients were managed (Table 1).
daily at the PHC by a single nurse clinician with weekly
medical officer support. During the study period from 2011 Pre-intervention (Figure 1)
to 2015, the South African Department of Health (DOH)
CD4 threshold for ART initiation was revised from 200 cells/ The study team assessed the baseline operational issues of the
+
mm in 2013 to < 500 cells/mm in 2015. 12 clinic to guide our interventions and focus. The review was
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conducted as follows: (1) In-depth file review (IDR); (2) VL and
Once initiated on ART, patients were followed up monthly by retention in care review (VLRIC); (3) VL management review
nurses who were responsible for clinical and laboratory (VLMR).
monitoring, dispensing of medications, re-enforcing adherence
messages and providing psychosocial support. Consultations Intervention period
focused on ART initiation and dispensing, with little time for Based on the in-depth review, the following combination
ensuring the accessing and management of VL results, or for of interventions was implemented: (1) training sessions;

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