Page 175 - SAHCS HIVMed Journal Vol 20 No 1 2019

Page 6 of 8 Original Research

improvements in management of HIV-positive patients with According to the South African ART guidelines, an elevated
raised VLs were noted, with a significant reduction in the VL (> 400 RNA copies/mL) indicates either poor treatment
number of patients who did not require a regimen change, and adherence or resistance, necessitating adherence support and
a significant increase in appropriate regimen changes post- drug therapy changes for treatment optimisation. 11,19 Low
intervention. adherence may also lead to virological failure, transmission
and drug resistance risk. 20,21,22 South African data highlight
In a South African study modelling national and provincial the increasing resistance patterns exacerbated by patients
HIV data, 78% of HIV-positive adults on ART had suppressed with an unsuppressed VL. 23
VLs in 2015; however, only 38% of HIV-positive adults
overall had virological suppression. Better virological There were several contributory factors to the success of our
13
suppression rates were reported in KwaZulu-Natal with 85% intervention. The project was conducted in a well-functioning
of HIV-positive patients on ART with undetectable VLs, but public health system with an inculcated culture of reflective
only 47% HIV-positive adults were virologically suppressed. data analysis and quality improvement. The NHLS system
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A notable finding of this study was that 73% of the patients facilitated the use of data to drive improvement as it is linked
who had a VL result available pre-intervention were to patient data that are meaningful to frontline staff. The health
virologically suppressed, lower than the national (78.4%) and system leadership used VL process data feedback to encourage
provincial estimates (excluding Limpopo and Mpumulanga). participation in learning opportunities and supported the
13
Virologic suppression was higher in this study than described testing of new ideas and the spread of successful interventions.
in other South African ART cohorts. However, under two-
14
thirds of patients had an available VL test and patients with Another factor for success was the perceived added value and
high VLs were not appropriately managed. acceptance of the intervention in the healthcare setting by the
staff who were using it. This acceptance is reflected by the large
The outcomes measured showed the effectiveness of the proportion of patient files with clinic summary sheets inserted
interventions, particularly the availability of VL results for by clinic staff. These results are also indicative of the feasibility
clinical management improving from 59% pre-intervention to of using summary sheets in busy healthcare settings. The clinical
87% post-intervention. There was also an improvement in summary sheet also proved useful for the completion of the
management of raised VLs, with a significant increase in required governmental forms for audit purposes. While there
repeat VL tests from 78% pre-intervention to 92% post- were fields to assist with integrated care provision such as
intervention. Furthermore, there was a significant increase in pregnancy or HIV-positive patients co-infected with TB, the
appropriate regimen changes from 11% pre-intervention to clinical summary chart was mainly used for ART management,
73% post-intervention, and timelier follow-up of these patients. and assessment of patient eligibility for down-referral to a
chronic club. While the initial investment in summarising
The findings of this study with a quality improvement patient data may be unwieldy, long term, the summary sheet
intervention focusing on the VL monitoring and recognition of may mitigate the necessity to peruse through long and often
treatment failure are similar to other studies in South Africa complex clinical notes, saving time for both the patient and
and Malawi. In a South African study in three clinics in provider during the consultation. Moreover, if there is
eThekwini in KwaZulu-Natal, a VL champion was designated substantial buy-in from staff, a clinical summary sheet could be
to focus on virologic management; following the intervention, inserted for all patients newly initiating on ART or pre-inserted
the VL tests performed significantly increased from under 70% into files of patients presenting for care the next day.
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at the three clinics to over 80%. In a study at 13 facilities in
Malawi over a 6-month period, changing staff roles with a VL There is limited data on the association between summary
‘focal person’ to oversee all VL activities improved VL testing sheets and improvement in clinical care; however, the
164% pre-intervention versus post-intervention. 16 integrated summary of prospectively collected clinical
information can assist clinical staff in organising complex
Furthermore, patients are vulnerable to non-adherence and patient data to facilitate management. 24
disengagement the longer they remain on treatment. In a
17
retrospective cohort study in Cape Town, South Africa, In South Africa, HIV care is decentralised to PHC level; ART
almost 23% of patients disengaged from care within 2 years initiation and follow-up care are primarily nurse-managed
of ART initiation with 16% requiring hospital admissions and with task shifting to less specialised health workers. Although
17
3% dying following disengagement. Moreover, the WHO- there are clear recommendations set out by the South African
defined VL threshold (VL ≥ 1000 copies/mL) for intervention ART treatment guidelines on the management of HIV-positive
of virological failure may not adequately identify patients at patients, 19,25 there is inadequate time for nurses to provide
risk for adverse clinical outcomes. In a recent South African comprehensive care because of the large volumes of patients.
study with over 69 000 patients, HIV-positive patients on With the focus on dispensing ART, opportunities for detailed
ART with low-level viraemia (≥ 50 copies/mL) were threefold clinical assessment, adherence and psychological support,
more likely to develop virologic failure than patients with which are crucial for the success of therapy, are missed, creating
undetectable VL; the risk increased to almost fivefold when major challenges for HIV-positive patients presenting with
using VL 400 copies/mL – 999 copies/mL. 18 complex disease to be managed timeously and appropriately.

http://www.sajhivmed.org.za 168 Open Access