A packaged intervention to improve viral load monitoring within a deeply rural health district of South Africa
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RESEARCH ARTICLE
Open Access
A packaged intervention to improve viral load monitoring within a deeply rural health district of South Africa J. Brijkumar1, B. A. Johnson2, Y. Zhao3, J. Edwards3, P. Moodley4, K. Pathan3, S. Pillay1, K. G. Castro3, H. Sunpath1, D. R. Kuritzkes5, M. Y. S. Moosa1 and V. C. Marconi3,6,7*
Abstract Background: The KwaZulu-Natal (KZN) province of South Africa has the highest prevalence of HIV infection in the world. Viral load (VL) testing is a crucial tool for clinical and programmatic monitoring. Within uMkhanyakude district, VL suppression rates were 91% among patients with VL data; however, VL performance rates averaged only 38·7%. The objective of this study was to determine if enhanced clinic processes and community outreach could improve VL monitoring within this district. Methods: A packaged intervention was implemented at three rural clinics in the setting of the KZN HIV AIDS Drug Resistance Surveillance Study. This included file hygiene, outreach, a VL register and documentation revisions. Chart audits were used to assess fidelity. Outcome measures included percentage VL performed and suppressed. Each rural clinic was matched with a peri-urban clinic for comparison before and after the start of each phase of the intervention. Monthly sample proportions were modelled using quasi-likelihood regression methods for over-dispersed binomial data. Results: Mkuze and Jozini clinics increased VL performance overall from 33·9% and 35·3% to 75·8% and 72·4%, respectively which was significantly greater than the increases in the comparison clinics (RR 1·86 and 1·68, p < 0·01). VL suppression rates similarly increased overall by 39·3% and 36·2% (RR 1·84 and 1·70, p < 0·01). The Chart Intervention phase showed significant increases in fidelity 16 months after implementation. Conclusions: The packaged intervention improved VL performance and suppression rates overall but was significant in Mkuze and Jozini. Larger sustained efforts will be needed to have a similar impact throughout the province. Keywords: HIV, Viral load, South Africa, Rural health, Virologic suppression, Monitoring
Background South Africa has the highest burden of human immunodeficiency virus (HIV) in the world with approximately 7·7 million people living with the disease. Therefore, South Africa, with 4.7 million (62%) people receiving antiretroviral therapy (ART), is home to the largest HIV treatment program in the world. Overall, according to * Correspondence: [email protected] 3 Emory University Rollins School of Public Health, Atlanta, GA, USA 6 Infectious Diseases, Emory University School of Medicine, Atlanta, GA, USA Full list of author information is available at the end of the article
United Nations Programme on HIV/AIDS (UNAIDS), the viral load (VL) suppression rate is 45% with 3·2 million of the 6·1 million people virologically suppressed [1]. The eastern coastal province of KwaZulu-Natal (KZN) experiences the highest burden of HIV infection in the country with 1·2 million people on treatment [2]. With the implem
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