Practices to improve identification of adult antiretroviral therapy failure at the Lighthouse Trust clinic in Lilongwe, Malawi

"They gave us the right to choose." A qualitative study of preferences for differentiated service delivery location among recipients of antiretroviral therapy at Lighthouse Trust in Lilongwe Malawi

Some differentiated service delivery (DSD) models for antiretroviral therapy (ART) allow stable recipients of care (RoC) to receive multi-month ART drug refills and complete rapid reviews in community sites. As DSD options expand across sub-Saharan Africa, RoC's preferences and perspectives on community-based DSD versus clinic-based care models warrants attention. Lighthouse Trust (LT) implements DSD services for the Ministry of Health in Lilongwe, Malawi, including a community-based ART service delivery model that complements it traditional, clinic-based care. In this qualitative study, we explore reasons why RoC enrolled in LT clinics and eligible for DSD chose clinic-based ART services or a Nurse-led Community-based ART Program (NCAP) that reaches clients in established community peer support groups. We conducted eight focus group discussions (FGDs) among LT RoC: four FGDs among NCAP groups and four clinic-based FGDs (2 per setting) to explore opinions, preferences, and perceptions about ART service delivery. FGDs were recorded in Chichewa, translated and transcribed into English for thematic analysis. Findings were discussed with LT and NCAP teams to ensure results resonated with their personal experiences. Sixty-three participants took part in FGDs. Many findings were similar across care model. Across both NCAP and clinic FGDs, RoC were pleased with the care quality and appreciated the convenience of integrating their appointment visits at their chosen care model into their daily lives. Across FGDs, RoC also appreciated the quality of care, the respectful provider-to-patient interactions, and the attention to privacy at community and clinic sites. RoC in both clinic and NCAP care models expressed satisfaction with their chosen care model and preferred that choice over alternative options and locations, some noting their willingness to travel far to access LT's high quality of clinic-based care. Privacy protection was an important consideration for choosing care models. At LT clinics, RoC highlighted the importance of physical separation between LT's HIV-specific service site and other care services. In NCAP, RoC expressed that their choice of care model was reinforced by the sense of mutual support they received through NCAP peer support. These findings suggest the importance of offering personal choice to RoC on care model and selection of DSD options to support their ongoing engagement in care.

Validation of a clinical prediction score to target viral load testing in adults with suspected first-line treatment failure in resource-constrained settings

BACKGROUND

Although routine viral load (VL) monitoring currently is too costly for poor countries, clinical failure criteria perform poorly. We previously developed an algorithm combining a clinical predictor score (CPS) with targeted VL testing in a Cambodian patient population (derivation population). We now prospectively validate the algorithm in the same clinical setting (validation population), assess its operational performance, and explore its cost-saving potential.

METHODS

We performed a cross-sectional study in a tertiary hospital in Phnom Penh, Cambodia, applying the CPS in adults on first-line antiretroviral treatment for at least 1 year. Treatment failure was defined as a VL >1000 copies per milliliter. The area under the receiver-operating characteristic (AUROC) curve of the CPS to detect treatment failure in the current study population (validation population) was compared with the AUROC of the CPS obtained in the patient population where the CPS was derived from in 2008 in the same study setting (derivation population). Costs related to VL testing and second-line regimens with the different testing strategies were compared.

RESULTS

One thousand four hundred ninety individuals {56.6% female, median age 38 years [interquartile range (IQR): 33-44]} were included, with a median baseline CD4 cell count of 94 cells per microliter (IQR: 28-205). Median time on antiretroviral treatment was 3.6 years (IQR: 2.1-5.1), 45 (3.0%) individuals had treatment failure. The AUROC of the CPS in validation was 0.75 (95% confidence interval: 0.67 to 0.83), relative to an AUROC of 0.70 in the derivation population. At the CPS cutoff ≥ 2, VL was indicated for 164 (11%) individuals, preventing inappropriate switching to second line in 143 cases. Twenty-four cases of treatment failure would be missed. When applied in routine care, the AUROC was 0.69 (95% confidence interval: 0.60 to 0.77). Overall 1-year program costs with targeted VL testing were 4-fold reduced.

CONCLUSIONS

The algorithm performed well in validation and has cost-saving potential. Further studies to assess its performance, feasibility, and impact in different settings are warranted.