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Patel RC, Oyaro P, Thomas KK, Basha GW, Wagude J, Mukui I, Brown E, Hassan SA, Kinywa E, Oluoch F, Odhiambo F, Oyaro B, Kingwara L, Karauki E, Yongo N, Otieno L, John‐Stewart GC, Abuogi LL. Impact of point-of-care HIV viral load and targeted drug resistance mutation testing on viral suppression among Kenyan pregnant and postpartum women: results from a prospective cohort study (Opt4Mamas). J Int AIDS Soc 2023; 26:e26182. [PMID: 37938856 PMCID: PMC10631517 DOI: 10.1002/jia2.26182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 09/21/2023] [Indexed: 11/10/2023] Open
Abstract
INTRODUCTION Lack of viral suppression (VS) among pregnant and breastfeeding women living with HIV poses challenges for maternal and infant health, and viral load (VL) monitoring via centralized laboratory systems faces many barriers. We aimed to determine the impact of point-of-care (POC) VL and targeted drug resistance mutation (DRM) testing in improving VS among pregnant and postpartum women on antiretroviral therapy. METHODS We conducted a pre/post-intervention prospective cohort study among 820 pregnant women accessing HIV care at five public-sector facilities in western Kenya from 2019 to 2022. The pre-intervention or "control" group consisted of standard-of-care (SOC) centralized VL testing every 6 months and the post-intervention or "intervention" group consisted of a combined strategy of POC VL every 3 months, targeted DRM testing, and clinical management support. The primary outcome was VS (VL ≤1000 copies/ml) at 6 months postpartum; secondary outcomes included uptake and turnaround times for VL testing and sustained VS. RESULTS At 6 months postpartum, 321/328 (98%) of participants in the intervention group and 339/347 (98%) in the control group achieved VS (aRR 1.00, 95% confidence interval [CI] 0.98, 1.02). When assessing VS using a threshold of <40 copies/ml, VS proportions were lower overall (90-91%) but remained similar between groups. Among women with viraemia (VL>1000 copies/ml) who underwent successful DRM testing in the intervention group, all (46/46, 100%) had some DRMs and 20 (43%) had major DRMs (of which 80% were nucleos(t)ide reverse transcriptase inhibitor mutations). POC VL testing uptake was high (>89%) throughout pregnancy, delivery, and postpartum periods, with a median turnaround time of 1 day (IQR 1, 4) for POC VL in the intervention group and 7 days (IQR 5, 9) for SOC VL in the control group. Sustained VS throughout follow-up was similar between groups with either POC or SOC VL testing (90-91% for <1000 copies/ml, 62-70% for <40 copies/ml). CONCLUSIONS Our combined strategy markedly decreased turnaround time but did not increase VS rates, which were already very high, or sustained VS among pregnant and postpartum women living with HIV. Further research on how best to utilize POC VL and DRM testing is needed to optimize sustained VS among this population.
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Affiliation(s)
- Rena C. Patel
- Department of MedicineUniversity of WashingtonSeattleWashingtonUSA
- Department of Global HealthUniversity of WashingtonSeattleWashingtonUSA
- Department of MedicineUniversity of AlabamaBirminghamUK
| | | | | | | | | | - Irene Mukui
- Drugs for Neglected Diseases Initiative (DNDI)NairobiKenya
| | | | - Shukri A. Hassan
- Department of MedicineUniversity of WashingtonSeattleWashingtonUSA
| | | | | | - Francesca Odhiambo
- Family AIDS Care and Education ServicesKenya Medical Research InstituteKisumuKenya
| | - Boaz Oyaro
- Kenya Medical Research Institute‐CDCKisianKenya
| | - Leonard Kingwara
- National HIV Reference LaboratoryKenya Ministry of HealthNairobiKenya
| | | | | | - Lindah Otieno
- Family AIDS Care and Education ServicesKenya Medical Research InstituteKisumuKenya
| | - Grace C. John‐Stewart
- Department of MedicineUniversity of WashingtonSeattleWashingtonUSA
- Department of Global HealthUniversity of WashingtonSeattleWashingtonUSA
- Departments of Pediatrics and EpidemiologyUniversity of WashingtonSeattleWashingtonUSA
| | - Lisa L. Abuogi
- Department of PediatricsUniversity of ColoradoDenverColoradoUSA
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Scallon AJ, Hassan SA, Qian SR, Gao Y, Oyaro P, Brown E, Wagude J, Mukui I, Kinywa E, Oluoch F, Odhiambo F, Oyaro B, Kingwara L, Yongo N, Karauki E, Otieno L, John-Stewart GC, Abuogi LL, Patel RC. "I feel drug resistance testing allowed us to make an informed decision": qualitative insights on the role of HIV drug resistance mutation testing among children and pregnant women living with HIV in western Kenya. BMC Health Serv Res 2023; 23:908. [PMID: 37620855 PMCID: PMC10463841 DOI: 10.1186/s12913-023-09804-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Accepted: 07/10/2023] [Indexed: 08/26/2023] Open
Abstract
BACKGROUND Pregnant women and children living with HIV in Kenya achieve viral suppression (VS) at lower rates than other adults. While many factors contribute to these low rates, the acquisition and development of HIV drug resistance mutations (DRMs) are a contributing factor. Recognizing the significance of DRMs in treatment decisions, resource-limited settings are scaling up national DRM testing programs. From provider and patient perspectives, however, optimal ways to operationalize and scale-up DRM testing in such settings remain unclear. METHODS Our mixed methods study evaluates the attitudes towards, facilitators to, and barriers to DRM testing approaches among children and pregnant women on antiretroviral therapy (ART) in five HIV treatment facilities in Kenya. We conducted 68 key informant interviews (KIIs) from December 2019 to December 2020 with adolescents, caregivers, pregnant women newly initiating ART or with a high viral load, and providers, laboratory/facility leadership, and policy makers. Our KII guides covered the following domains: (1) DRM testing experiences in routine care and through our intervention and (2) barriers and facilitators to routine and point-of-care DRM testing scale-up. We used inductive coding and thematic analysis to identify dominant themes with convergent and divergent subthemes. RESULTS The following themes emerged from our analysis: (1) DRM testing and counseling were valuable to clinical decision-making and reassuring to patients, with timely results allowing providers to change patient ART regimens faster; (2) providers and policymakers desired an amended and potentially decentralized DRM testing process that incorporates quicker sample-to-results turn-around-time, less burdensome procedures, and greater patient and provider "empowerment" to increase comfort with testing protocols; (3) facility-level delays, deriving from overworked facilities and sample tracking difficulties, were highlighted as areas for improvement. CONCLUSIONS DRM testing has the potential to considerably improve patient health outcomes. Key informants recognized several obstacles to implementation and desired a more simplified, time-efficient, and potentially decentralized DRM testing process that builds provider comfort and confidence with DRM testing protocols. Further investigating the implementation, endurance, and effectiveness of DRM testing training is critical to addressing the barriers and areas of improvement highlighted in our study. TRIAL REGISTRATION NCT03820323.
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Affiliation(s)
- Andrea J Scallon
- Jackson School of International Studies, University of Washington, Seattle, USA
| | - Shukri A Hassan
- Department of Medicine, University of Washington, 325 9th Ave, Seattle, WA, 98105, USA
| | | | - Yuandi Gao
- School of Public Health, University of Washington, Seattle, USA
| | | | | | | | - Irene Mukui
- Drugs for Neglected Diseases Initiative, Nairobi, Kenya
| | | | | | - Francesca Odhiambo
- Family AIDS Care and Education Services, Kenya Medical Research Institute, Kisumu, Kenya
| | - Boaz Oyaro
- Kenya Medical Research Institute-CDC, Kisian, Kenya
| | - Leonard Kingwara
- National HIV Reference Laboratory, Ministry of Health, Nairobi, Kenya
| | | | | | - Lindah Otieno
- Family AIDS Care and Education Services, Kenya Medical Research Institute, Kisumu, Kenya
| | - Grace C John-Stewart
- Department of Medicine, University of Washington, 325 9th Ave, Seattle, WA, 98105, USA
- Departments of Global Health, University of Washington, 325 9th Ave, WA, 98105, Seattle, USA
- Department of Pediatrics, University of Washington, Seattle, USA
- Department of Epidemiology, University of Washington, Seattle, USA
| | - Lisa L Abuogi
- Department of Pediatrics, University of Colorado, Denver, USA
| | - Rena C Patel
- Department of Medicine, University of Washington, 325 9th Ave, Seattle, WA, 98105, USA.
- Departments of Global Health, University of Washington, 325 9th Ave, WA, 98105, Seattle, USA.
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