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Ferraris CM, D'avanzo PA, Jennings L, Robbins RN, Nguyen N, Leu CS, Dolezal C, Mgbako O, Hsiao NY, Joska J, Castillo-Mancilla JR, Myer L, Anderson PL, Belaunzarán-Zamudio PF, Mellins CA, Orrell C, Remien RH. Acceptability and Feasibility of Providing Adherence Feedback Based on Tenofovir Diphosphate in Dried Blood Spots: Results from a Pilot Study Among Patients and Providers in Cape Town, South Africa. AIDS Behav 2023; 27:3478-3486. [PMID: 37043053 PMCID: PMC10811583 DOI: 10.1007/s10461-023-04063-7] [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] [Accepted: 04/05/2023] [Indexed: 04/13/2023]
Abstract
Tenofovir diphosphate (TFV-DP) concentrations in dried blood spots (DBS) predict viral breakthrough, but their use remains understudied in real-world clinic settings. This pilot study examined acceptability, feasibility, and initial adherence outcomes of providing adherence feedback using TFV-DP concentrations on patient- and provider-levels in Cape Town, South Africa. We enrolled 60 persons with HIV (PWH) receiving tenofovir-containing ART attending a primary health clinic. They were randomized 1:1 to an intervention receiving TFV-DP concentration feedback by research staff vs. no feedback at monthly visits for 4 months. Acceptability among medical providers and level of clinical follow-up of TFV-DP results was examined. Patient acceptability was assessed descriptively. Mean electronic adherence (EA), as measured by WisePill device, and TFV-DP in DBS were compared between the two arms. All participants in the intervention group (100%) reported finding TFV-DP feedback helpful and 86% reported changing adherence behaviors. Medical providers indicated high acceptability of incorporating TFV-DP concentration feedback into the clinic, yet among 29 results < 1000 fmol/punch, only 2 were reviewed with no follow-up actions performed. In the intervention arm, mean TFV-DP concentrations were significantly higher (t = 2.5, p < .01) during follow-up and EA in upper quartile (96-100%) was greater compared to controls (x2 = 7.8, p ≤ .05). This study found high acceptability among patients for receiving adherence feedback based on TFV-DP concentrations. TFV-DP and EA data demonstrated greater adherence in the intervention group. Providers indicated high acceptability of incorporating TFV-DP feedback into the clinic, but few providers reviewed results, which could impact clinic-level feasibility.
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Affiliation(s)
- Christopher M Ferraris
- HIV Center for Clinical and Behavioral Studies, Psychiatric Institute, Columbia University, New York, NY, USA.
- Division of Gender, Sexuality and Health, New York State Psychiatric Institute, 1051 Riverside Drive, New York, NY, 10032, USA.
| | - Paul A D'avanzo
- HIV Center for Clinical and Behavioral Studies, Psychiatric Institute, Columbia University, New York, NY, USA
| | - Lauren Jennings
- Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine, Department of Medicine, University of Cape Town, Cape Town, South Africa.
- Desmond Tutu Health Foundation, 3 Woodlands Rd, Woodstock, Cape Town, 7925, South Africa.
| | - Reuben N Robbins
- HIV Center for Clinical and Behavioral Studies, Psychiatric Institute, Columbia University, New York, NY, USA
| | - Nadia Nguyen
- Aaron Diamond AIDS Research Center, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - Cheng-Shiun Leu
- Columbia University Mailman School of Public Health, New York, NY, USA
| | - Curtis Dolezal
- HIV Center for Clinical and Behavioral Studies, Psychiatric Institute, Columbia University, New York, NY, USA
| | - Ofole Mgbako
- Division of Infectious Diseases, Department of Medicine, NYU Langone Health, New York, NY, USA
| | - Nei-Yuan Hsiao
- National Health Laboratory Service, Cape Town, South Africa
- University of Cape Town, Cape Town, South Africa
| | - John Joska
- University of Cape Town, Cape Town, South Africa
| | | | - Landon Myer
- Division of Epidemiology & Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
| | | | - Pablo F Belaunzarán-Zamudio
- Contractor for the National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Claude A Mellins
- HIV Center for Clinical and Behavioral Studies, Psychiatric Institute, Columbia University, New York, NY, USA
| | - Catherine Orrell
- Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Robert H Remien
- HIV Center for Clinical and Behavioral Studies, Psychiatric Institute, Columbia University, New York, NY, USA
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2
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Broyles LN, Luo R, Boeras D, Vojnov L. The risk of sexual transmission of HIV in individuals with low-level HIV viraemia: a systematic review. Lancet 2023; 402:464-471. [PMID: 37490935 PMCID: PMC10415671 DOI: 10.1016/s0140-6736(23)00877-2] [Citation(s) in RCA: 29] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 04/14/2023] [Accepted: 04/25/2023] [Indexed: 07/27/2023]
Abstract
BACKGROUND The risk of sexual transmission of HIV from individuals with low-level HIV viraemia receiving antiretroviral therapy (ART) has important public health implications, especially in resource-limited settings that use alternatives to plasma-based viral load testing. This Article summarises the evidence related to sexual transmission of HIV at varying HIV viral load levels to inform messaging for people living with HIV, their partners, their health-care providers, and the wider public. METHODS We conducted a systematic review and searched PubMed, MEDLINE, Cochrane Central Register of Controlled Trials, Embase, Conference Proceedings Citation Index-Science, and WHO Global Index Medicus, for work published from Jan 1, 2010 to Nov 17, 2022. Studies were included if they pertained to sexual transmission between serodiscordant couples at various levels of viraemia, the science behind undetectable=untransmittable, or the public health impact of low-level viraemia. Studies were excluded if they did not specify viral load thresholds or a definition for low-level viraemia or did not provide quantitative viral load information for transmission outcomes. Reviews, non-research letters, commentaries, and editorials were excluded. Risk of bias was evaluated using the ROBINS-I framework. Data were extracted and summarised with a focus on HIV sexual transmission at varying HIV viral loads. FINDINGS 244 studies were identified and eight were included in the analysis, comprising 7762 serodiscordant couples across 25 countries. The certainty of evidence was moderate; the risk of bias was low. Three studies showed no HIV transmission when the partner living with HIV had a viral load less than 200 copies per mL. Across the remaining four prospective studies, there were 323 transmission events; none were in patients considered stably suppressed on ART. Among all studies there were two cases of transmission when the index patient's (ie, patient with previously diagnosed HIV infection) most recent viral load was less than 1000 copies per mL. However, interpretation of both cases was complicated by long intervals (ie, 50 days and 53 days) between the transmission date and the most recent index viral load result. INTERPRETATION There is almost zero risk of sexual transmission of HIV with viral loads of less than 1000 copies per mL. These data provide a powerful opportunity to destigmatise HIV and promote adherence to ART through dissemination of this positive public health message. These findings can also promote access to viral load testing in resource-limited settings for all people living with HIV by facilitating uptake of alternative sample types and technologies. FUNDING Bill & Melinda Gates Foundation.
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Affiliation(s)
| | - Robert Luo
- Global Health Impact Group, Atlanta, GA, USA
| | - Debi Boeras
- Global Health Impact Group, Atlanta, GA, USA
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3
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The Development of a Standardized Quality Assessment Material to Support Xpert ® HIV-1 Viral Load Testing for ART Monitoring in South Africa. Diagnostics (Basel) 2021; 11:diagnostics11020160. [PMID: 33499162 PMCID: PMC7911816 DOI: 10.3390/diagnostics11020160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 01/17/2021] [Accepted: 01/19/2021] [Indexed: 11/17/2022] Open
Abstract
The tiered laboratory framework for human immunodeficiency virus (HIV) viral load monitoring accommodates a range of HIV viral load testing platforms, with quality assessment critical to ensure quality patient testing. HIV plasma viral load testing is challenged by the instability of viral RNA. An approach using an RNA stabilizing buffer is described for the Xpert® HIV-1 Viral Load (Cepheid) assay and was tested in remote laboratories in South Africa. Plasma panels with known HIV viral titres were prepared in PrimeStore molecular transport medium for per-module verification and per-instrument external quality assessment. The panels were transported at ambient temperatures to 13 testing laboratories during 2017 and 2018, tested according to standard procedures and uploaded to a web portal for analysis. A total of 275 quality assessment specimens (57 verification panels and two EQA cycles) were tested. All participating laboratories met study verification criteria (n = 171 specimens) with an overall concordance correlation coefficient (ρc) of 0.997 (95% confidence interval (CI): 0.996 to 0.998) and a mean bias of −0.019 log copies per milliliter (cp/mL) (95% CI: −0.044 to 0.063). The overall EQA ρc (n = 104 specimens) was 0.999 (95% CI: 0.998 to 0.999), with a mean bias of 0.03 log cp/mL (95% CI: 0.02 to 0.05). These panels are suitable for use in quality monitoring of Xpert® HIV-1 VL and are applicable to laboratories in remote settings.
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Gueguen M, Nicholas S, Poulet E, Schramm B, Szumilin E, Wolters L, Wapling J, Ajule E, Rakesh A, Mwenda R, Kiyaga C, Balkan S. Implementation and operational feasibility of SAMBA I HIV-1 semi-quantitative viral load testing at the point-of-care in rural settings in Malawi and Uganda. Trop Med Int Health 2020; 26:184-194. [PMID: 33159822 DOI: 10.1111/tmi.13519] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE We monitored a large-scale implementation of the Simple Amplification-Based Assay semi-quantitative viral load test for HIV-1 version I (SAMBA I Viral Load = SAMBA I VL) within Médecins Sans Frontières' HIV programmes in Malawi and Uganda, to assess its performance and operational feasibility. METHODS Descriptive analysis of routine programme data between August 2013 and December 2016. The dataset included samples collected for VL monitoring and tested using SAMBA I VL in five HIV clinics in Malawi (four peripheral health centres and one district hospital), and one HIV clinic in a regional referral hospital in Uganda. SAMBA I VL was used for VL testing in patients who had been receiving ART for between 6 months and ten years, to determine whether plasma VL was above or below 1000 copies/mL of HIV-1, reflecting ART failure or efficacy. Randomly selected samples were quantified with commercial VL assays. SAMBA I instruments and test performance, site throughput, and delays in communicating results to clinicians and patients were monitored. RESULTS Between August 2013 and December 2016 a total of 60 889 patient samples were analysed with SAMBA I VL. Overall, 0.23% of initial SAMBA I VL results were invalid; this was reduced to 0.04% after repeating the test once. Global test failure, including instrument failure, was 1.34%. Concordance with reference quantitative testing of VL was 2620/2727, 96.0% (1338/1382, 96.8% in Malawi; 1282/1345, 95.3% in Uganda). For Chiradzulu peripheral health centres and Arua Hospital HIV clinic, where testing was performed on-site, same-day results were communicated to clinicians for between 91% and 97% of samples. Same-day clinical review was obtained for 84.7% across the whole set of samples tested. CONCLUSIONS SAMBA I VL testing is feasible for monitoring cohorts of 1000 to 5000 ART-experienced patients. Same-day results can be used to inform rapid clinical decision-making at rural and remote health facilities, potentially reducing time available for development of resistance and conceivably helping to reduce morbidity and mortality.
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Newman H, Hardie D. HIV-1 viral load testing in resource-limited settings: Challenges and solutions for specimen integrity. Rev Med Virol 2020; 31:e2165. [PMID: 32978882 DOI: 10.1002/rmv.2165] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 08/20/2020] [Accepted: 08/22/2020] [Indexed: 11/07/2022]
Abstract
HIV-1 viral load (VL) testing is a crucial element in providing an antiretroviral treatment monitoring program. The success of these programs depends on the availability and quality of the VL testing services. There are several pre-analytic factors which can affect the quality of VL testing. Many of the challenges faced by resource-limited countries result in a compromise of specimen integrity, thus limiting widespread access to VL monitoring. The various logistic and financial challenges that exist are not insurmountable and several innovative solutions currently exist to overcome these barriers to providing widespread VL testing. This review summarizes the VL testing challenges in resource-limited settings and provides an overview of potential solutions including testing dried blood spots, dried plasma spots, plasma separation cards and the use of point of care tests.
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Affiliation(s)
- Howard Newman
- National Health Laboratory Service, South Africa.,Department of Pathology, Division of Medical Virology, Stellenbosch University, Stellenbosch, South Africa.,Faculty of Health Sciences, Nelson Mandela University, Port Elizabeth, South Africa
| | - Diana Hardie
- National Health Laboratory Service, South Africa.,Department of Pathology, Division of Virology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
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Fuellen G, Liesenfeld O, Kowald A, Barrantes I, Bastian M, Simm A, Jansen L, Tietz-Latza A, Quandt D, Franceschi C, Walter M. The preventive strategy for pandemics in the elderly is to collect in advance samples & data to counteract chronic inflammation (inflammaging). Ageing Res Rev 2020; 62:101091. [PMID: 32454090 PMCID: PMC7245683 DOI: 10.1016/j.arr.2020.101091] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 05/07/2020] [Accepted: 05/18/2020] [Indexed: 12/15/2022]
Abstract
Fighting the current COVID-19 pandemic, we must not forget to prepare for the next. Since elderly and frail people are at high risk, we wish to predict their vulnerability, and intervene if possible. For example, it would take little effort to take additional swabs or dried blood spots. Such minimally-invasive sampling, exemplified here during screening for potential COVID-19 infection, can yield the data to discover biomarkers to better handle this and the next respiratory disease pandemic. Longitudinal outcome data can then be combined with other epidemics and old-age health data, to discover the best biomarkers to predict (i) coping with infection & inflammation and thus hospitalization or intensive care, (ii) long-term health challenges, e.g. deterioration of lung function after intensive care, and (iii) treatment & vaccination response. Further, there are universal triggers of old-age morbidity & mortality, and the elimination of senescent cells improved health in pilot studies in idiopathic lung fibrosis & osteoarthritis patients alike. Biomarker studies are needed to test the hypothesis that resilience of the elderly during a pandemic can be improved by countering chronic inflammation and/or removing senescent cells. Our review suggests that more samples should be taken and saved systematically, following minimum standards, and data be made available, to maximize healthspan & minimize frailty, leading to savings in health care, gains in quality of life, and preparing us better for the next pandemic, all at the same time.
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Yacouba A, Congo M, Dioma GK, Somlare H, Coulidiaty D, Ouattara K, Sangare L. Whatman FTA cards versus plasma specimens for the quantitation of HIV-1 RNA using two real-time PCR assays. Access Microbiol 2020; 2:acmi000138. [PMID: 32974600 PMCID: PMC7497827 DOI: 10.1099/acmi.0.000138] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Accepted: 02/17/2020] [Indexed: 11/24/2022] Open
Abstract
Background Several studies have compared the use of dried blot spot (DBS) as an alternative to plasma specimens, mainly using Whatman 903 cards as filter paper. The aim of this study was to evaluate the use of Whatman FTA card (FTA card) specimens for HIV-1 viral load testing compared to plasma specimens using two real-time PCR assays manufactured by Roche and Abbott. Methodology A cross-sectional study was conducted between April 2017 and September 2017 on HIV-1 patients admitted to Yalgado Ouédraogo Teaching Hospital. Paired FTA cards and plasma specimens were collected and analysed using the Abbott Real-Time HIV-1 assay (Abbott) and COBAS AmpliPrep/COBAS TaqMan v2.0 (Roche). Results In total, 107 patients were included. No statistical differences (P>0.05) were observed between the mean viral loads obtained from the FTA cards and those of the plasma specimens using the Roche and Abbott assays. In total, 29 samples with Roche and 15 samples with Abbott assay showed discrepant results. At viral loads of ≤1000 copies ml−1, the sensitivity and specificity of the FTA cards were 78.6 and 100% with Roche, and 92.3 and 95.9% with Abbott, respectively. Both the Roche and Abbott assays showed good correlation and agreement between the FTA cards and plasma values. Conclusion Our study demonstrates the feasibility of using FTA card filter paper for HIV-1 viral load testing. However, further studies will be required for the validation of the use of FTA card filter paper in HIV-1 treatment monitoring.
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Affiliation(s)
- Abdourahamane Yacouba
- Laboratoire National de Référence du VIH/Sida et des Infections Sexuellement Transmissibles, Centre Hospitalier Universitaire Yalgado Ouédraogo, 03 B.P. 7022 Ouaga 03, Ouagadougou, Burkina Faso
| | - Malika Congo
- Laboratoire National de Référence du VIH/Sida et des Infections Sexuellement Transmissibles, Centre Hospitalier Universitaire Yalgado Ouédraogo, 03 B.P. 7022 Ouaga 03, Ouagadougou, Burkina Faso
| | - Gérard Komonsira Dioma
- Laboratoire National de Référence du VIH/Sida et des Infections Sexuellement Transmissibles, Centre Hospitalier Universitaire Yalgado Ouédraogo, 03 B.P. 7022 Ouaga 03, Ouagadougou, Burkina Faso
| | - Hermann Somlare
- Laboratoire National de Référence du VIH/Sida et des Infections Sexuellement Transmissibles, Centre Hospitalier Universitaire Yalgado Ouédraogo, 03 B.P. 7022 Ouaga 03, Ouagadougou, Burkina Faso
| | - David Coulidiaty
- Laboratoire National de Référence du VIH/Sida et des Infections Sexuellement Transmissibles, Centre Hospitalier Universitaire Yalgado Ouédraogo, 03 B.P. 7022 Ouaga 03, Ouagadougou, Burkina Faso
| | - Kalifa Ouattara
- Laboratoire National de Référence du VIH/Sida et des Infections Sexuellement Transmissibles, Centre Hospitalier Universitaire Yalgado Ouédraogo, 03 B.P. 7022 Ouaga 03, Ouagadougou, Burkina Faso
| | - Lassana Sangare
- Unité de Formation et des Recherches en Sciences de la Santé, Université Ouaga I Pr Joseph KI-ZERBO, 03 B.P. 7021 Ouaga 03, Ouagadougou, Burkina Faso
- Laboratoire National de Référence du VIH/Sida et des Infections Sexuellement Transmissibles, Centre Hospitalier Universitaire Yalgado Ouédraogo, 03 B.P. 7022 Ouaga 03, Ouagadougou, Burkina Faso
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Nicholas S, Poulet E, Wolters L, Wapling J, Rakesh A, Amoros I, Szumilin E, Gueguen M, Schramm B. Point-of-care viral load monitoring: outcomes from a decentralized HIV programme in Malawi. J Int AIDS Soc 2020; 22:e25387. [PMID: 31441242 PMCID: PMC6706700 DOI: 10.1002/jia2.25387] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Accepted: 07/31/2019] [Indexed: 11/16/2022] Open
Abstract
Introduction Routinely monitoring the HIV viral load (VL) of people living with HIV (PLHIV) on anti‐retroviral therapy (ART) facilitates intensive adherence counselling and faster ART regimen switch when treatment failure is indicated. Yet standard VL‐testing in centralized laboratories can be time‐intensive and logistically difficult in low‐resource settings. This paper evaluates the outcomes of the first four years of routine VL‐monitoring using Point‐of‐Care technology, implemented by Médecins Sans Frontières (MSF) in rural clinics in Malawi. Methods We conducted a retrospective cohort analysis of patients eligible for routine VL‐ testing between 2013 and 2017 in four decentralized ART‐clinics and the district hospital in Chiradzulu, Malawi. We assessed VL‐testing coverage and the treatment failure cascade (from suspected failure (first VL>1000 copies/mL) to VL suppression post regimen switch). We used descriptive statistics and multivariate logistic regression to assess factors associated with suspected failure. Results and Discussion Among 21,400 eligible patients, VL‐testing coverage was 85% and VL suppression was found in 89% of those tested. In the decentralized clinics, 88% of test results were reviewed on the same day as blood collection, whereas in the district hospital the median turnaround‐time for results was 85 days. Among first‐line ART patients with suspected failure (N = 1544), 30% suppressed (VL<1000 copies/mL), 35% were treatment failures (confirmed by subsequent VL‐testing) and 35% had incomplete VL follow‐up. Among treatment failures, 80% (N = 540) were switched to a second‐line regimen, with a higher switching rate in the decentralized clinics than in the district hospital (86% vs. 67%, p < 0.01) and a shorter median time‐to‐switch (6.8 months vs. 9.7 months, p < 0.01). Similarly, the post‐switch VL‐testing rate was markedly higher in the decentralized clinics (61% vs. 26%, p < 0.01). Overall, 79% of patients with a post‐switch VL‐test were suppressed. Conclusions Viral load testing at the point‐of‐care in Chiradzulu, Malawi achieved high coverage and good drug regimen switch rates among those identified as treatment failures. In decentralized clinics, same‐day test results and shorter time‐to‐switch illustrated the game‐changing potential of POC‐based VL‐testing. Nevertheless, gaps were identified along all steps of the failure cascade. Regular staff training, continuous monitoring and creating demand are essential to the success of routine VL‐testing.
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Feasibility of dried blood spots for HIV viral load monitoring in decentralized area in North Vietnam in a test-and-treat era, the MOVIDA project. PLoS One 2020; 15:e0230968. [PMID: 32271796 PMCID: PMC7145146 DOI: 10.1371/journal.pone.0230968] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Accepted: 03/12/2020] [Indexed: 11/30/2022] Open
Abstract
Background Access to HIV viral load is crucial to efficiently monitor patients on antiretroviral treatment (ART) and prevent HIV drug resistance acquisition. However, in some remote settings, access to viral load monitoring is still complex due to logistical and financial constraints. Use of dried blood spots (DBS) for blood collection could overcome these difficulties. This study aims to describe feasibility and operability of DBS use for routine viral load monitoring. Methods From June 2017 to April 2018, HIV-infected adults who initiated ART were enrolled in a prospective cohort in 43 clinical sites across 6 provinces in North Vietnam. Following national guidelines, the first viral load monitoring was planned 6 months after ART initiation. DBS were collected at the clinical site and sent by post to a central laboratory in Hanoi for viral load measurement. Results Of the 578 patients enrolled, 537 were still followed 6 months after ART initiation, of which DBS was collected for 397 (73.9%). The median (inter quartile range) delay between DBS collection at site level and reception at the central laboratory was 8 (6–19) days and for 70.0% viral load was measured ≤30 days after blood collection. The proportion of patients with viral load ≥1000 copies/mL at the 6 month evaluation was 15.9% (n = 59). Of these, a DBS was collected again to confirm virological failure in 15 (24.4%) of which virological failure was confirmed in 11 (73.3%). Conclusion Delay of DBS transfer to the central laboratory was acceptable and most viral loads were measured in ≤30 days, in-line with routine follow-up. However, the level of DBS coverage and the proportion of patients in failure for whom a confirmatory viral load was available were suboptimal, indicating that integration of viral load monitoring in the field requires, among other things, careful training and strong involvement of the local teams. The proportion of patients experiencing virological failure was in line with other reports; interestingly those who reported being non-adherent and those with a low BMI were more at risk of failure.
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Hubbard J, Kakwesa G, Nyirenda M, Mwambene J, Bardon A, Balakasi K, Dovel K, Kalua T, Hoffman RM. Towards the third 90: improving viral load testing with a simple quality improvement program in health facilities in Malawi. Int Health 2019; 11:215-220. [PMID: 30383224 DOI: 10.1093/inthealth/ihy083] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Revised: 08/31/2018] [Accepted: 09/18/2018] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Viral load (VL) scale-up efforts have largely focused on laboratory systems, with less attention on facility-level strengthening of staff who facilitate VL testing. To address this gap we implemented a quality improvement (QI) program at 13 health facilities in central and southern Malawi. METHODS QI program tools focused on patient and provider VL knowledge and clarification of site-level roles and responsibilities, including the designation of a VL 'focal person' to oversee all VL activities. T-tests were used to compare differences in VL testing before (November 2016-April 2017) and after (May 2017-November 2017) the intervention. RESULTS The mean number of VL tests performed significantly increased after implementation of the QI program. Overall there was a 164% increase in the mean number of routine VL tests performed per month (p<0.001). Increased VL testing was sustained during the 6 months of follow-up. CONCLUSIONS A simple QI program focused on improving VL knowledge among patients and providers, and clarifying staff roles at a facility level increased VL testing over a 6-month period. Further investigation is needed on whether this program can be scaled in different settings across sub-Saharan Africa and on the duration of follow-up required for sustained improvements in VL testing.
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Affiliation(s)
- Julie Hubbard
- Department of Medicine, Division of Infectious Diseases, David Geffen School of Medicine at the University of California Los Angeles, 10833 Le Conte Avenue, 37-121 CHS, Los Angeles, CA, USA.,Partners in Hope/EQUIP
| | | | | | | | - Ashley Bardon
- Department of Medicine, Division of Infectious Diseases, David Geffen School of Medicine at the University of California Los Angeles, 10833 Le Conte Avenue, 37-121 CHS, Los Angeles, CA, USA.,Partners in Hope/EQUIP
| | | | - Kathryn Dovel
- Department of Medicine, Division of Infectious Diseases, David Geffen School of Medicine at the University of California Los Angeles, 10833 Le Conte Avenue, 37-121 CHS, Los Angeles, CA, USA.,Partners in Hope/EQUIP
| | - Thokozani Kalua
- Ministry of Health, Department of HIV and AIDS, Area 3, Lilongwe, Malawi
| | - Risa M Hoffman
- Department of Medicine, Division of Infectious Diseases, David Geffen School of Medicine at the University of California Los Angeles, 10833 Le Conte Avenue, 37-121 CHS, Los Angeles, CA, USA
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Sikombe K, Hantuba C, Musukuma K, Sharma A, Padian N, Holmes C, Czaicki N, Simbeza S, Somwe P, Bolton-Moore C, Sikazwe I, Geng E. Accurate dried blood spots collection in the community using non-medically trained personnel could support scaling up routine viral load testing in resource limited settings. PLoS One 2019; 14:e0223573. [PMID: 31622394 PMCID: PMC6797100 DOI: 10.1371/journal.pone.0223573] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Accepted: 09/24/2019] [Indexed: 12/20/2022] Open
Abstract
Regular plasma HIV-RNA testing for persons living with HIV on antiretroviral therapy (ART) is now the global standard, but as many as 60% of persons in Africa today on ART do not have access to standard laboratory HIV-RNA assays. As a result, patients in Zambia often receive treatment without any means of determining true virologic failure, which poses a risk of premature switch of ART regimens and widespread HIV drug resistance. Dry blood spots (DBS) on the other hand require unskilled personnel and less complex storage supply chain so are ideal to capture viral-load results from HIV patients outside clinic settings. We assess collection of DBS in the community using non-medically trained personnel (NMP) and documented challenges. We trained 23 NMP to collect DBS from lost to follow-up (LTFU) patients in 4 rural and urban Zambian districts. We developed a phlebotomy box to transport DBS without contamination at ambient temperature and concomitant training and standard operating procedures. We evaluated this through field observations, bi-weekly meetings, reports, and staff meetings. The laboratory assessed DBS quality for testing validity. We attempted to collect DBS from 357 participants in the community. Though individual reasons for refusal from the remaining 37% were not collected, NMPs reported privacy concerns, awkward box-size which drew attention in the community and fears of undisclosed uses of samples related to witchcraft and circulating narratives about past research. Successful DBS collection was not associated with patient gender, age, time on ART, enrolment CD4, facility. DBS viral-load collection by NMP is feasible in Zambia. Our training approach and assessments of NMP not part of the health system can be extended to patients by giving them more responsibility to manage their own differentiated care groups. Concerted efforts that compare collection of DBS by NMP to those collected by skilled-medical personnel are needed.
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Affiliation(s)
| | - Cardinal Hantuba
- Centre for Infectious Diseases Research in Zambia, Lusaka, Zambia
| | - Kalo Musukuma
- Centre for Infectious Diseases Research in Zambia, Lusaka, Zambia
| | - Anjali Sharma
- Centre for Infectious Diseases Research in Zambia, Lusaka, Zambia
| | - Nancy Padian
- Division of Epidemiology, University of California, Berkeley, Berkeley, California, United States of America
| | - Charles Holmes
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
- Center for Global Health and Quality, Georgetown University, Washington, District of Columbia, United States of America
| | - Nancy Czaicki
- Centre for Infectious Diseases Research in Zambia, Lusaka, Zambia
- Division of HIV, Infectious Diseases and Global Medicine, University of California, San Francisco, Zuckerberg San Francisco General Hospital, San Francisco, California, United States of America
| | - Sandra Simbeza
- Centre for Infectious Diseases Research in Zambia, Lusaka, Zambia
| | - Paul Somwe
- Centre for Infectious Diseases Research in Zambia, Lusaka, Zambia
| | - Carolyn Bolton-Moore
- Centre for Infectious Diseases Research in Zambia, Lusaka, Zambia
- Division of Infectious Diseases, University of Alabama, Birmingham, Alabama, United States of America
| | - Izukanji Sikazwe
- Centre for Infectious Diseases Research in Zambia, Lusaka, Zambia
| | - Elvin Geng
- Division of HIV, Infectious Diseases and Global Medicine, University of California, San Francisco, Zuckerberg San Francisco General Hospital, San Francisco, California, United States of America
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12
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Zalla LC, Herce ME, Edwards JK, Michel J, Weir SS. The burden of HIV among female sex workers, men who have sex with men and transgender women in Haiti: results from the 2016 Priorities for Local AIDS Control Efforts (PLACE) study. J Int AIDS Soc 2019; 22:e25281. [PMID: 31287624 PMCID: PMC6615490 DOI: 10.1002/jia2.25281] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Accepted: 04/05/2019] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Despite the higher risk of HIV among female sex workers (FSWs), men who have sex with men (MSM) and transgender women (TGW), these populations are under-represented in the literature on HIV in Haiti. Here, we present the first nationally representative estimates of HIV prevalence and the first care and treatment cascade for FSWs, MSM and TGW in Haiti. We also examine the social determinants of HIV prevalence in these groups and estimate FSW and MSM population size in Haiti. METHODS Data were collected between April 2016 and February 2017 throughout the 10 geographical departments of Haiti. The Priorities for Local AIDS Control Efforts (PLACE) method was used to: (1) recruit participants for a behavioural survey; (2) provide rapid testing, counselling and linkage to care for syphilis and HIV; and (3) measure viral load using dried blood spots for participants testing HIV positive. RESULTS Study participants included 990 FSWs, 520 MSM and 109 TGW. HIV prevalence was estimated at 7.7% (95% CI 6.2%, 9.6%) among FSWs, 2.2% (0.9%, 5.3%) among MSM and 27.6% (5.0%, 73.5%) among TGW. Of participants who tested positive for syphilis, 17% of FSWs, 19% of MSM and 74% of TGW were co-infected with HIV. Economic instability and intimate partner violence (IPV) were significantly associated with HIV among MSM; food insecurity, economic instability and history of rape were significantly associated with HIV among TGW. Fewer than one-third of participants living with HIV knew their status, and more than a quarter of those who knew their status were not on treatment. While approximately four in five FSW and MSM participants on treatment for HIV were virally suppressed, viral suppression was less common among TGW participants at only 46%. CONCLUSIONS This study demonstrates a need for targeted interventions to prevent and treat HIV among key populations in Haiti. Potential high-impact interventions may include venue-based, peer navigator-led outreach and testing for HIV and syphilis and improving screening and case management for structural violence and IPV. TGW are in urgent need of such interventions due to our observations of alarmingly high HIV prevalence and low frequency of HIV viral suppression among TGW.
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Affiliation(s)
- Lauren C Zalla
- Department of EpidemiologyUniversity of North Carolina at Chapel HillChapel HillNCUSA
- Carolina Population CenterUniversity of North Carolina at Chapel HillChapel HillNCUSA
| | - Michael E Herce
- Division of Infectious DiseasesDepartment of MedicineUniversity of North Carolina at Chapel HillChapel HillNCUSA
| | - Jessie K Edwards
- Department of EpidemiologyUniversity of North Carolina at Chapel HillChapel HillNCUSA
| | | | - Sharon S Weir
- Department of EpidemiologyUniversity of North Carolina at Chapel HillChapel HillNCUSA
- Carolina Population CenterUniversity of North Carolina at Chapel HillChapel HillNCUSA
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13
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Nyanza EC, Dewey D, Bernier F, Manyama M, Hatfield J, Martin JW. Validation of Dried Blood Spots for Maternal Biomonitoring of Nonessential Elements in an Artisanal and Small-Scale Gold Mining Area of Tanzania. ENVIRONMENTAL TOXICOLOGY AND CHEMISTRY 2019; 38:1285-1293. [PMID: 30900767 DOI: 10.1002/etc.4420] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Revised: 11/22/2018] [Accepted: 03/15/2019] [Indexed: 06/09/2023]
Abstract
Biomonitoring studies of vulnerable populations in low- and middle-income countries are limited because traditional sampling methods are challenging to implement in low-resource settings. The present study examined the feasibility, precision, and accuracy of dried blood spots (DBS) for human biomonitoring of nonessential elements (cadmium [Cd], mercury [Hg], and lead [Pb]) in an area of northern Tanzania with artisanal and small-scale gold mining activities. Pregnant women (n = 44) were recruited in Geita during antenatal clinic visits, and DBS from capillary blood were collected on filter paper. As a gold-standard comparison, venous blood was sampled from the same participants and compared with the DBS. Venous blood, DBS, and quality control samples were analyzed for chemical elements by inductively coupled plasma mass spectrometry. Field blanks were very clean for most elements, generally only twice as high as corresponding laboratory filter blanks. No significant differences were found between duplicate DBS samples taken from the same participants, with near perfect intraclass correlation coefficients (0.99) for Cd, Hg, and Pb, indicating excellent reliability. Moreover, correlation was strong (r2 > 0.9) and significant (p < 0.0001) between DBS and the quantitative venous blood, with regression line slopes close to 1.0 (0.847, 0.976, and 0.969 for Cd, Hg, and Pb, respectively), indicating high accuracy of the DBS method compared with the gold-standard approach. The DBS method is minimally invasive and was a feasible, precise, and accurate means of measuring exposure to Cd, Hg, and Pb in pregnant women in a low-resource setting. Environ Toxicol Chem 2019;38:1285-1293. © 2019 SETAC.
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Affiliation(s)
- Elias C Nyanza
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Environmental, Occupational Health and GIS, School of Public Health, Catholic University of Health and Allied Sciences, Bugando Area, Mwanza, Tanzania
| | - Deborah Dewey
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Francois Bernier
- Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Medical Genetics, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Mange Manyama
- Division of Medical Education, Weill-Cornell Medicine-Qatar, Doha, Qatar
| | - Jennifer Hatfield
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Jonathan W Martin
- Science for Life Laboratory, Department of Environmental Sciences and Analytical Chemistry, Stockholm University, Stockholm, Sweden
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14
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Thepbundit V, Ngo-Giang-Huong N, Salvadori N, Laolue A, Kunyanone N, Sata-Un J, Jourdain G, Sirirungsi W, Khamduang W. Feasibility of using dried blood spots for HIV viral load testing among HIV-infected individuals in Thailand using QIAGEN QIAsymphony-artus HIV-1 platform. J Med Virol 2019; 91:1652-1659. [PMID: 31095748 DOI: 10.1002/jmv.25506] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2019] [Revised: 04/25/2019] [Accepted: 05/14/2019] [Indexed: 01/08/2023]
Abstract
In settings where plasma preparation and sample centralization are not feasible or inconvenient, dried blood spots (DBS) could be used as an alternative specimen to plasma to assess antiretroviral treatment response among HIV-infected individuals. This study was aimed to (1) validate the recent QIAsymphony-artus assay for DBS HIV viral load (VL) and (2) assess the feasibility of measuring HIV VL on DBS using this assay in Thailand. Ethylenediaminetetraacetic acid-blood samples from 99 HIV-infected individuals were used to prepare paired DBS and plasma. Also, DBS samples were shipped to three distant hospitals in the northern region. After short-term storage, DBS were returned by regular post to the AMS laboratory and were re-tested for HIV VL using the same platform. HIV VL results were compared using Pearson's correlation and Bland-Altman analysis. DBS HIV VL fairly correlated to plasma HIV VL (R = 0.62) with a mean difference of 0.02 log10 IU/mL (SD = 1.06). A high correlation (R = 0.79) was observed between HIV VL in DBS before and after shipping (mean difference = 0.14 log10 IU/mL, SD = 0.74), indicating good stability of HIV RNA in DBS. DBS can be used as an alternative specimen for HIV VL monitoring in Thailand. However, measurement of HIV VL with the QIAGEN QIAsymphony-artus assay should be improved, especially the DBS pre-extraction process.
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Affiliation(s)
- Viraporn Thepbundit
- Department of Medical Technology, Faculty of Associated Medical Sciences (AMS), Chiang Mai University, Chiangmai, Thailand
| | - Nicole Ngo-Giang-Huong
- Department of Medical Technology, Faculty of Associated Medical Sciences (AMS), Chiang Mai University, Chiangmai, Thailand.,Unité Internationale174-PHPT, Health and Societies Department, Institut de Recherche pour Développement (IRD), Chiangmai, Thailand.,Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Nicolas Salvadori
- Department of Medical Technology, Faculty of Associated Medical Sciences (AMS), Chiang Mai University, Chiangmai, Thailand.,Unité Internationale174-PHPT, Health and Societies Department, Institut de Recherche pour Développement (IRD), Chiangmai, Thailand
| | - Auswin Laolue
- Department of Medical Laboratory, Wiangsa Hospital, Nan, Thailand
| | - Naowarat Kunyanone
- Department of Medical Laboratory, Chiangrai Prachanukroh Hospital, Chiangrai, Thailand
| | - Jaggrit Sata-Un
- Department of Medical Laboratory, Thoeng Hospital, Chiangrai, Thailand
| | - Gonzague Jourdain
- Department of Medical Technology, Faculty of Associated Medical Sciences (AMS), Chiang Mai University, Chiangmai, Thailand.,Unité Internationale174-PHPT, Health and Societies Department, Institut de Recherche pour Développement (IRD), Chiangmai, Thailand.,Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Wasna Sirirungsi
- Department of Medical Technology, Faculty of Associated Medical Sciences (AMS), Chiang Mai University, Chiangmai, Thailand
| | - Woottichai Khamduang
- Department of Medical Technology, Faculty of Associated Medical Sciences (AMS), Chiang Mai University, Chiangmai, Thailand.,Infectious Diseases Research Unit, Department of Medical Technology, Faculty of Associated Medical Sciences, Chiang Mai University, Chiangmai, Thailand
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15
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Point-of-Care HIV Viral Load Testing: an Essential Tool for a Sustainable Global HIV/AIDS Response. Clin Microbiol Rev 2019; 32:32/3/e00097-18. [PMID: 31092508 DOI: 10.1128/cmr.00097-18] [Citation(s) in RCA: 61] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
The global public health community has set ambitious treatment targets to end the HIV/AIDS pandemic. With the notable absence of a cure, the goal of HIV treatment is to achieve sustained suppression of an HIV viral load, which allows for immunological recovery and reduces the risk of onward HIV transmission. Monitoring HIV viral load in people living with HIV is therefore central to maintaining effective individual antiretroviral therapy as well as monitoring progress toward achieving population targets for viral suppression. The capacity for laboratory-based HIV viral load testing has increased rapidly in low- and middle-income countries, but implementation of universal viral load monitoring is still hindered by several barriers and delays. New devices for point-of-care HIV viral load testing may be used near patients to improve HIV management by reducing the turnaround time for clinical test results. The implementation of near-patient testing using these new and emerging technologies may be an essential tool for ensuring a sustainable response that will ultimately enable an end to the HIV/AIDS pandemic. In this report, we review the current and emerging technology, the evidence for decentralized viral load monitoring by non-laboratory health care workers, and the additional considerations for expanding point-of-care HIV viral load testing.
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16
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Separation of Plasma from Whole Blood by Use of the cobas Plasma Separation Card: a Compelling Alternative to Dried Blood Spots for Quantification of HIV-1 Viral Load. J Clin Microbiol 2019; 57:JCM.01336-18. [PMID: 30728197 PMCID: PMC6440768 DOI: 10.1128/jcm.01336-18] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Accepted: 01/23/2019] [Indexed: 12/21/2022] Open
Abstract
Plasma HIV viral load testing is the preferred means of monitoring antiretroviral treatment response. Dried blood spots (DBSs) hold considerable logistical advantages over EDTA samples, but they more frequently misclassify virological failure and have higher limits of detection (LoD). Plasma separation cards (PSCs) may overcome these limitations. Health workers collected EDTA whole blood by venipuncture and 140 μl of finger-prick blood by capillary tube from 53 HIV-infected adults. Capillary blood was immediately transferred to PSCs. Additionally, 432 EDTA samples from HIV-infected adults were spotted onto PSCs and analyzed together with the finger-prick samples. Specificity and sensitivity of PSC with paired EDTA-PSC samples tested on a cobas 6800/8800 system with the cobas HIV-1 test (cobas HIV) was determined. LoD (3rd HIV-1 WHO International Standard) and stability at a range of temperatures and storage durations was determined using cobas HIV and cobas AmpliPrep/cobas TaqMan HIV-1 test v2.0 (CAP/CTM). Of 132 specimens with quantitative values for paired EDTA-PSC samples, the mean log10 difference between samples was 0.05 copies/ml (95% confidence interval [CI], -0.01 to 0.11). The LoD for cobas HIV was 790.2 copies/ml and for CAP/CTM was 737.9 copies/ml. At 1,000 copies/ml, PSC sensitivity was 97.0% (128/132) and specificity was 97.2% (343/353). Results correlated well with those from EDTA samples (Deming R 2 = 0.90). PSC results were unaffected by temperature and storage conditions. PSC samples correlate well with plasma viral load and have adequate sensitivity and specificity. The improved performance may be as a result of a reduction in contribution from cell-associated viral nucleic acids. The card provides an alternative sample collection technology to DBSs.
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17
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Mungwira RG, Divala TH, Nyirenda OM, Kanjala M, Muwalo F, Mkandawire FA, Choko A, Taylor TE, Mallewa J, van Oosterhout JJ, Laufer MK, Laurens MB. A targeted approach for routine viral load monitoring in Malawian adults on antiretroviral therapy. Trop Med Int Health 2018; 23:526-532. [PMID: 29505108 DOI: 10.1111/tmi.13047] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
OBJECTIVES WHO recommends HIV viral load (VL) testing 6 months after antiretroviral therapy (ART) initiation and every 12 months thereafter, but cost prohibits routine, universal VL testing in many developing countries. We sought to devise a targeted approach to routine VL monitoring that could reduce cost and identify those at low risk for virologic failure (VF). METHODS We analysed screening data from a clinical trial enrolling adults on ART in Malawi. We identified risk factors associated with VF and employed the Knill-Jones method to assign summary score identifying persons at lower risk for VF. RESULTS Among 957 adults, prevalence of VF was 9.4%. Factors independently associated with VF included age <38 years (OR 3.44, 95% CI 2.01-5.89), ART duration >2.5 years (OR 2.98, 95% CI 1.79-4.96), ART adherence <95% (OR 1.76, 95% CI 1.06-2.94), CD4 count <200 cells/μl (OR 5.94, 95% CI 3.27-10.78), haemoglobin <13 g/dl (OR 2.76, 95% CI 1.70-4.50) and CD8 count >885 cells/μl (OR 2.10, 95% CI 1.28-3.44). Our VF prediction summary score included all factors above except CD8 count and was fairly accurate with validated area under receiver operating characteristic curve of 0.76. Implementation could reduce VL testing by 65%. CONCLUSION A simple score incorporating age, ART duration and adherence, and CD4 count can accurately identify adults at low risk for VF in a sub-Saharan African setting. In areas with high ART utilisation and limited VL testing capacity, a targeted approach could optimise routine VL monitoring while identifying adults in need of alternate ART regimens.
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Affiliation(s)
- Randy G Mungwira
- Blantyre Malaria Project, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Titus H Divala
- Blantyre Malaria Project, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Osward M Nyirenda
- Blantyre Malaria Project, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Maxwell Kanjala
- Blantyre Malaria Project, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Francis Muwalo
- Blantyre Malaria Project, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Felix A Mkandawire
- Blantyre Malaria Project, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Augustine Choko
- Malawi Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Terrie E Taylor
- Blantyre Malaria Project, College of Medicine, University of Malawi, Blantyre, Malawi.,Department of Internal Medicine, Michigan State University, East Lansing, MI, USA
| | - Jane Mallewa
- Department of Medicine, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Joep J van Oosterhout
- Department of Medicine, College of Medicine, University of Malawi, Blantyre, Malawi.,Dignitas International, Zomba, Malawi
| | - Miriam K Laufer
- Division of Malaria Research, Institute for Global Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Matthew B Laurens
- Division of Malaria Research, Institute for Global Health, University of Maryland School of Medicine, Baltimore, MD, USA
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18
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Saito S, Duong YT, Metz M, Lee K, Patel H, Sleeman K, Manjengwa J, Ogollah FM, Kasongo W, Mitchell R, Mugurungi O, Chimbwandira F, Moyo C, Maliwa V, Mtengo H, Nkumbula T, Ndongmo CB, Vere NS, Chipungu G, Parekh BS, Justman J, Voetsch AC. Returning HIV-1 viral load results to participant-selected health facilities in national Population-based HIV Impact Assessment (PHIA) household surveys in three sub-Saharan African Countries, 2015 to 2016. J Int AIDS Soc 2018; 20 Suppl 7. [PMID: 29171193 PMCID: PMC5978652 DOI: 10.1002/jia2.25004] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Accepted: 08/21/2017] [Indexed: 11/21/2022] Open
Abstract
Introduction Logistical complexities of returning laboratory test results to participants have precluded most population‐based HIV surveys conducted in sub‐Saharan Africa from doing so. For HIV positive participants, this presents a missed opportunity for engagement into clinical care and improvement in health outcomes. The Population‐based HIV Impact Assessment (PHIA) surveys, which measure HIV incidence and the prevalence of viral load (VL) suppression in selected African countries, are returning VL results to health facilities specified by each HIV positive participant within eight weeks of collection. We describe the performance of the specimen and data management systems used to return VL results to PHIA participants in Zimbabwe, Malawi and Zambia. Methods Consenting participants underwent home‐based counseling and HIV rapid testing as per national testing guidelines; all confirmed HIV positive participants had VL measured at a central laboratory on either the Roche CAP/CTM or Abbott m2000 platform. On a bi‐weekly basis, a dedicated data management team produced logs linking the VL test result with the participants’ contact information and preferred health facility; project staff sent test results confidentially via project drivers, national courier systems, or electronically through an adapted short message service (SMS). Participants who provided cell phone numbers received SMS or phone call alerts regarding availability of VL results. Results and discussion From 29,634 households across the three countries, 78,090 total participants 0 to 64 years in Zimbabwe and Malawi and 0 to 59 years in Zambia underwent blood draw and HIV testing. Of the 8391 total HIV positive participants identified, 8313 (99%) had VL tests performed and 8245 (99%) of these were returned to the selected health facilities. Of the 5979 VL results returned in Zimbabwe and Zambia, 85% were returned within the eight‐week goal with a median turnaround time of 48 days (IQR: 33 to 61). In Malawi, where exact return dates were unavailable all 2266 returnable results reached the health facilities by 11 weeks. Conclusions The first three PHIA surveys returned the vast majority of VL results to each HIV positive participant's preferred health facility within the eight‐week target. Even in the absence of national VL monitoring systems, a system to return VL results from a population‐based survey is feasible, but it requires developing laboratory and data management systems and dedicated staff. These are likely important requirements to strengthen return of results systems in routine clinical care.
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Affiliation(s)
- Suzue Saito
- ICAP at Columbia University, New York, NY, USA.,Department of Epidemiology, Mailman School of Public Health at Columbia University, New York, NY, USA
| | - Yen T Duong
- ICAP at Columbia University, New York, NY, USA
| | | | - Kiwon Lee
- ICAP at Columbia University, New York, NY, USA
| | - Hetal Patel
- Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Katrina Sleeman
- Centers for Disease Control and Prevention, Atlanta, GA, USA
| | | | | | | | | | - Owen Mugurungi
- Zimbabwe Ministry of Health and Child Care, Harare, Zimbabwe
| | | | | | | | | | | | | | | | | | - Bharat S Parekh
- Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Jessica Justman
- ICAP at Columbia University, New York, NY, USA.,Department of Epidemiology, Mailman School of Public Health at Columbia University, New York, NY, USA
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19
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Pollack TM, Duong HT, Truong PT, Pham TT, Do CD, Colby D. Sensitivity and specificity of two dried blood spot methods for HIV-1 viral load monitoring among patients in Hanoi, Vietnam. PLoS One 2018; 13:e0191411. [PMID: 29346431 PMCID: PMC5773210 DOI: 10.1371/journal.pone.0191411] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Accepted: 12/18/2017] [Indexed: 11/23/2022] Open
Abstract
The use of dried blood spot (DBS) specimens for HIV viral load (VL) monitoring is recommended to support the roll-out of routine VL monitoring in low and middle income countries (LMICs). To better understand the use of DBS for VL monitoring, we evaluated two DBS testing methods, Roche TaqMan® Free Virus Evolution protocol (DBS-FVE) and Roche TaqMan® SPEX protocol (DBS-SPEX)) in patients receiving ART at an HIV clinic in Hanoi, Vietnam. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated for each DBS testing method at the thresholds of 1000 and 5000 copies/ml compared to plasma VL. At a threshold of 1000 copies/ml, sensitivity, specificity, PPV and NPV of the DBS-SPEX method were 98.8% (95% CI: 93.3%-100%), 74.3% (95% CI: 70.8%-77.5%), 31.5% (95% CI: 25.8%-37.6%), and 99.8% (95% CI: 98.9%-100%), respectively. Increasing the VL threshold value to 5000 copies/ml improved specificity (97.9% CI: 96.6%-98.9%) and PPV (83.9% CI: 74.5%-90.9%). Using the DBS-FVE method, at the threshold of 1000 copies/ml and with a correction factor of +0.3 log copies/ml, sensitivity was 95.1% (87.8%-98.6%) and specificity was 98.8% (97.7%-99.5%). Sensitivity decreased at the threshold of 5000 copies/ml (65.8%, 95% CI: 54.3%-76.1%). With a correction factor of +0.7 log copies/ml, the sensitivity was 96.3% (89.6%-99.2%) and specificity was 98.2% (96.9%-99.1%) at the threshold of 1000 copies/ml. We found that the Roche DBS-FVE method, with a +0.7 log copies/ml correction factor, performed well with sensitivity and specificity greater than 96% at a VL threshold of 1000 copies/m. These findings add to the growing body of evidence supporting the use of DBS VL testing for ART monitoring. Future research should evaluate the association between VL results by DBS and clinical outcome measures such as HIV drug resistance, morbidity, and mortality.
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Affiliation(s)
- Todd M. Pollack
- The Partnership for Health Advancement in Vietnam, Beth Israel Deaconess Medical Center, Hanoi, Vietnam
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States of America
- * E-mail:
| | - Hao T. Duong
- The Partnership for Health Advancement in Vietnam, Beth Israel Deaconess Medical Center, Hanoi, Vietnam
| | | | - Thuy T. Pham
- The Partnership for Health Advancement in Vietnam, Beth Israel Deaconess Medical Center, Hanoi, Vietnam
- Department of Infectious Diseases, Bach Mai Hospital, Hanoi, Vietnam
| | - Cuong D. Do
- Department of Infectious Diseases, Bach Mai Hospital, Hanoi, Vietnam
| | - Donn Colby
- Center for Applied Research on Men and Community Health, Ho Chi Minh City, Vietnam
- SEARCH, Thai Red Cross AIDS Research Centre, Bangkok, Thailand
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20
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Technological methods to measure adherence to antiretroviral therapy and preexposure prophylaxis. Curr Opin HIV AIDS 2017; 12:467-474. [PMID: 28590335 DOI: 10.1097/coh.0000000000000393] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW The WHO's Consolidated Guidelines (2016) call for research on improved methods to proactively monitor adherence and identify those individuals who have the greatest needs for adherence support. This review aims to elucidate the latest technologies available to measure adherence to HIV antiretroviral therapy and preexposure prophylaxis against HIV infection and present their utility in various settings and populations. RECENT FINDINGS Within the last few years, advances have been made in the features of existing technology to measure adherence (real-time electronic adherence measurements), additional approaches have been developed (digital medicine systems) and improved (short message service surveys), and point of care testing for pharmacokinetic measures are under development. SUMMARY Technology advances in adherence measurement are promising for improved accuracy and, in some cases, the ability to intervene with adherence challenges in real time. This progress will greatly further our understanding of adherence behavior, as well as the ability to effectively link interventions with individuals who need them, thus maximizing the clinical and public health benefits of both antiretroviral therapy and preexposure prophylaxis.
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21
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Comparison of different nucleic acid preparation methods to improve specific HIV-1 RNA isolation for viral load testing on dried blood spots. J Virol Methods 2017; 251:75-79. [PMID: 29038002 DOI: 10.1016/j.jviromet.2017.10.014] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2017] [Revised: 10/12/2017] [Accepted: 10/13/2017] [Indexed: 11/21/2022]
Abstract
In resource-limited countries (RLCs), WHO recommends HIV viral load (VL) on dried blood spots (DBS) for antiretroviral therapy (ART) monitoring of patients living in non-urban settings where plasma VL is not available. In order to reduce the impact of proviral DNA interference, leading to false positive results in samples with low plasma VL, we compared three different nucleic acid preparation methods with the NucliSens (Biomérieux) extraction, known for its high recovery of nucleic acids on DBS. Paired plasma-DBS samples (n=151) with predominantly low plasma VL (≤10,000 copies/ml; 74%) were used. At the threshold of 1,000 copies/ml on DBS, 51% and 10% were misclassified as false positives or false negatives, respectively with NucliSens, versus 41% and 20% with m2000sp (Abbott), described as more specific for RNA recovery. DNase treatments of nucleic acid extracts and free virus elution (FVE) protocol before nucleic acid extraction, reduced the proportion of false positives to 0% and 19%, but increased the proportion of false negatives to 40% and 73%. More efforts are thus still needed to improve performance of VL assays on DBS to monitor patients on ART in RLCs and allow timely switch to more costly second or third line ART regimes.
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22
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Swannet S, Decroo T, de Castro SMTL, Rose C, Giuliani R, Molfino L, Torrens AW, Macueia WSED, Perry S, Reid T. Journey towards universal viral load monitoring in Maputo, Mozambique: many gaps, but encouraging signs. Int Health 2017; 9:206-214. [PMID: 28810670 PMCID: PMC5881256 DOI: 10.1093/inthealth/ihx021] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Accepted: 07/04/2017] [Indexed: 11/25/2022] Open
Abstract
Introduction Viral load (VL) monitoring for people on antiretroviral therapy (ART) is extremely challenging in resource-limited settings. We assessed the VL testing scale-up in six Médecins Sans Frontières supported health centres in Maputo, Mozambique, during 2014–15. Methods In a retrospective cohort study, routine programme data were used to describe VL testing uptake and results, and multi-variate logistical regression to estimate predictors of VL testing uptake and suppression. Results Uptake of a first VL test was 40% (17 236/43 579). Uptake of a follow-up VL test for patients with a high first VL result was 35% (1095/3100). Factors associated with a higher uptake included: age below 15 years, longer time on ART and attending tailored service delivery platforms. Virological suppression was higher in pregnant/breastfeeding women and in community ART Group members. Patients with a high first VL result (18%; 3100/17 236) were mostly younger, had been on ART longer or had tuberculosis. Out of 1095 attending for a follow-up VL test, 678 (62%) had virological failure. Of those, less than one-third had started second line ART. Conclusion This was the first study describing the uptake and results of VL testing scale-up in Mozambique. Identified gaps show patient and programmatic challenges. Where service delivery was customized to patient needs, VL monitoring was more successful.
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Affiliation(s)
- Sarah Swannet
- Operational Centres Geneva and Brussels, Médecins sans Frontières, Maputo, Mozambique
| | - Tom Decroo
- Operational Research Unit, Médecins sans Frontières, Luxembourg, Luxembourg
| | | | - Caroline Rose
- Operational Centres Geneva and Brussels, Médecins sans Frontières, Maputo, Mozambique
| | - Ruggero Giuliani
- Operational Centres Geneva and Brussels, Médecins sans Frontières, Maputo, Mozambique
| | - Lucas Molfino
- Operational Centres Geneva and Brussels, Médecins sans Frontières, Maputo, Mozambique
| | - Ana W Torrens
- Operational Centres Geneva and Brussels, Médecins sans Frontières, Maputo, Mozambique
| | - Walter S E D Macueia
- Operational Centres Geneva and Brussels, Médecins sans Frontières, Maputo, Mozambique
| | - Sharon Perry
- Southern Africa Medical Unit, Médecins sans Frontières, Cape Town, South Africa
| | - Tony Reid
- Operational Research Unit, Médecins sans Frontières, Luxembourg, Luxembourg
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Abstract
PURPOSE OF REVIEW In 2015, the WHO urged countries to provide ART to all people living with HIV, irrespective of their CD4 cell count, this new recommendation supports the Joint United Nations Programme on HIV/AIDS elimination targets. However, to meet these aims, urgent scale-up of viral load testing is critical. The multiple interventions in the healthcare system required to support scale-up of viral load testing are reviewed here. RECENT FINDINGS It is estimated that 18.2 million individuals are accessing antiretroviral therapy, consequently this will cause significant demand for viral load monitoring; however, at the current rate of implementation, demand will not meet the required target by 2020. To change this trajectory, multiple stakeholders must be involved, communities and key populations need increased treatment literacy to create demand and greater numbers of healthcare workers will require training. In addition, laboratories and point-of-care testing sites will need to be expanded, and adequate monitoring and evaluation tools will need to be put in place to identify gaps in the system, to institute prompt corrective actions and to direct resources where needed. SUMMARY Sufficient scale-up of viral load may well be possible if innovations in mHealth are used to support healthcare workers and patients with regard to the scale-up and effective use of viral load monitoring; new laboratory technologies are implemented, both at a centralized level and point-of-care, to manage higher volumes and improve coverage; and there is careful coordination between implementing partners and funders.
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24
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Rutstein SE, Compliment K, Nelson JAE, Kamwendo D, Mataya R, Miller WC, Hosseinipour MC. Differentiated Care Pathways for Antiretroviral Therapy Monitoring in Malawi: Expanding Viral Load Testing in Setting of Highly Prevalent Resistance. Open Forum Infect Dis 2017; 4:ofx125. [PMID: 30591918 PMCID: PMC6300304 DOI: 10.1093/ofid/ofx125] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Accepted: 06/14/2017] [Indexed: 11/15/2022] Open
Abstract
We quantified resistance to first-line antiretroviral therapy among previously unmonitored patients in Malawi with viremia (≥1000 copies/mL). Ninety-five percent (n = 57/61) harbored nucleoside/tide reverse transcriptase inhibitor/non-nucleoside reverse transcriptase inhibitor resistance; resistance was more common comparing >2 (97%) versus ≤2 years (87%) on therapy. Immediate switch for persons retained in care may improve monitoring efficiency and maximize clinical outcomes.
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Affiliation(s)
- Sarah E Rutstein
- Department of Health Policy and Management, University of North Carolina at Chapel Hill.,Division of Infectious Diseases, University of North Carolina at Chapel Hill
| | - Kara Compliment
- UNC Center for AIDS Research, University of North Carolina at Chapel Hill.,Department of Microbiology and Immunology, University of North Carolina at Chapel Hill
| | - Julie A E Nelson
- UNC Center for AIDS Research, University of North Carolina at Chapel Hill.,Department of Microbiology and Immunology, University of North Carolina at Chapel Hill
| | | | - Ronald Mataya
- School of Public Health, Loma Linda University, California
| | - William C Miller
- Division of Infectious Diseases, University of North Carolina at Chapel Hill.,Department of Epidemiology, University of North Carolina at Chapel Hill
| | - Mina C Hosseinipour
- Division of Infectious Diseases, University of North Carolina at Chapel Hill.,UNC Project, Lilongwe, Malawi
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25
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Field Evaluation of Dried Blood Spots for HIV-1 Viral Load Monitoring in Adults and Children Receiving Antiretroviral Treatment in Kenya: Implications for Scale-up in Resource-Limited Settings. J Acquir Immune Defic Syndr 2017; 74:399-406. [PMID: 28002185 DOI: 10.1097/qai.0000000000001275] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND The World Health Organization recommends viral load (VL) as the preferred method for diagnosing antiretroviral therapy failure; however, operational challenges have hampered the implementation of VL monitoring in most resource-limited settings. This study evaluated the accuracy of dried blood spot (DBS) VL testing under field conditions as a practical alternative to plasma in determining virologic failure (VF). METHODS From May to December 2013, paired plasma and DBS specimens were collected from 416 adults and 377 children on antiretroviral therapy for ≥6 months at 12 clinics in Kenya. DBSs were prepared from venous blood (V-DBS) using disposable transfer pipettes and from finger-prick capillary blood using microcapillary tubes (M-DBS) and directly spotting (D-DBS). All samples were tested on the Abbott m2000 platform; V-DBS was also tested on the Roche COBAS Ampliprep/COBAS TaqMan (CAP/CTM) version 2.0 platform. VF results were compared at 3 DBS thresholds (≥1000, ≥3000, and ≥5000 copies/mL) and a constant plasma threshold of ≥1000 copies/mL. RESULTS On the Abbott platform, at ≥1000-copies/mL threshold, sensitivities, specificities, and kappa values for VF determination were ≥88.1%, ≥93.1%, and ≥0.82%, respectively, for all DBS methods, and it had the lowest percentage of downward misclassification compared with higher thresholds. V-DBS performance on CAP/CTM had significantly poorer specificity at all thresholds (1000%-33.0%, 3000%-60.9%, and 5000%-77.0%). No significant differences were found between adults and children. CONCLUSIONS VL results from V-DBS, M-DBS, and D-DBS were comparable with those from plasma for determining VF using the Abbott platform but not with CAP/CTM. A 1000-copies/mL threshold was optimal and should be considered for VF determination using DBS in adults and children.
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26
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Gibb J, Chitsulo J, Chipungu C, Chivwara M, Schooley A, Hoffman RM. Supporting Quality Data Systems: Lessons Learned from Early Implementation of Routine Viral Load Monitoring at a Large Clinic in Lilongwe, Malawi. ACTA ACUST UNITED AC 2017; 3. [PMID: 28702463 DOI: 10.14302/issn.2324-7339.jcrhap-17-1468] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Successful viral load programs rely on the presence of data systems and high quality of patient data. Using a cohort of 49 patients at Partners in Hope, a large, urban HIV clinic in Malawi, we performed a quality improvement assessment of a new viral load program with a focus on accuracy of data collected from patients as well as adherence to Malawi HIV Guidelines in regard to response to elevated viral loads (≥1,000 copies/mL). Data were obtained from three parallel medical record systems to investigate the proportion of patients with a repeat viral load and whether the three data systems agreed in regard to sociodemographic and clinical data. Fewer than 30% of patients had a repeat viral load within six months, as recommended in the Malawi HIV Guidelines. There were significant problems with data agreement across the three parallel databases used for care. Date of birth was consistent for 55.1% (N=27) of patients, while a different date of birth was noted in all three sources for 10.2% of pateints (N=1). For 65.3% (N=32), the viral load from the laboratory did not match the recorded viral load in the electronic or paper record. Scale-up of viral load monitoring must be accompanied by the development of data systems that support workflow from sample collection to lab and back to provider. Education of providers and strategies for data collection with minimal errors can facilitate scale-up of high quality programs.
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Affiliation(s)
- Jean Gibb
- Resident physician, Internal Medicine, University of California, Los Angeles Medical Center, 757 Westwood Plaza, Suite 7501, Los Angeles, CA 90095, Mobile: +1-253-691-6253
| | - Jimmy Chitsulo
- Partners in Hope Medical Center, PO Box 302, Lilongwe, Malawi, Tele: +265 (0) 1-727-155
| | - Chifundo Chipungu
- Partners in Hope Medical Center, PO Box 302, Lilongwe, Malawi, Tele: +265 (0) 1-727-155
| | - Mackenzie Chivwara
- PO Box 302, Partners in Hope Medical Center, Lilongwe, Malawi, Tele: +265 (0) 1-727-155
| | - Alan Schooley
- Country Director, Partners in Hope Medical Center, PO Box 302, Lilongwe, Malawi, +265 994 425691
| | - Risa M Hoffman
- Associate Professor of Medicine, Division of Infectious Diseases, David Geffen School of Medicine at UCLA, Univeristy of California Los Angeles, 10833 Le Conte Ave, 37-121 CHS, Los Angeles, California, USA 90095, Mobile: +1-310-623-0671
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27
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Specimen origin, type and testing laboratory are linked to longer turnaround times for HIV viral load testing in Malawi. PLoS One 2017; 12:e0173009. [PMID: 28235013 PMCID: PMC5325555 DOI: 10.1371/journal.pone.0173009] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Accepted: 02/13/2017] [Indexed: 11/29/2022] Open
Abstract
Background Efforts to reach UNAIDS’ treatment and viral suppression targets have increased demand for viral load (VL) testing and strained existing laboratory networks, affecting turnaround time. Longer VL turnaround times delay both initiation of formal adherence counseling and switches to second-line therapy for persons failing treatment and contribute to poorer health outcomes. Methods We utilized descriptive statistics and logistic regression to analyze VL testing data collected in Malawi between January 2013 and March 2016. The primary outcomes assessed were greater-than-median pretest phase turnaround time (days elapsed from specimen collection to receipt at the laboratory) and greater-than-median test phase turnaround time (days from receipt to testing). Results The median number of days between specimen collection and testing increased 3-fold between 2013 (8 days, interquartile range (IQR) = 6–16) and 2015 (24, IQR = 13–39) (p<0.001). Multivariable analysis indicated that the odds of longer pretest phase turnaround time were significantly higher for specimen collection districts without laboratories capable of conducting viral load tests (adjusted odds ratio (aOR) = 5.16; 95% confidence interval (CI) = 5.04–5.27) as well as for Malawi’s Northern and Southern regions. Longer test phase turnaround time was significantly associated with use of dried blood spots instead of plasma (aOR = 2.30; 95% CI = 2.23–2.37) and for certain testing months and testing laboratories. Conclusion Increased turnaround time for VL testing appeared to be driven in part by categorical factors specific to the phase of turnaround time assessed. Given the implications of longer turnaround time and the global effort to scale up VL testing, addressing these factors via increasing efficiencies, improving quality management systems and generally strengthening the VL spectrum should be considered essential components of controlling the HIV epidemic.
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28
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Phillips AN, Cambiano V, Nakagawa F, Bansi-Matharu L, Sow PS, Ehrenkranz P, Ford D, Mugurungi O, Apollo T, Murungu J, Bangsberg DR, Revill P. Cost Effectiveness of Potential ART Adherence Monitoring Interventions in Sub-Saharan Africa. PLoS One 2016; 11:e0167654. [PMID: 27977702 PMCID: PMC5157976 DOI: 10.1371/journal.pone.0167654] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2016] [Accepted: 11/17/2016] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Interventions based around objective measurement of adherence to antiretroviral drugs for HIV have potential to improve adherence and to enable differentiation of care such that clinical visits are reduced in those with high adherence. It would be useful to understand the approximate upper limit of cost that could be considered for such interventions of a given effectiveness in order to be cost effective. Such information can guide whether to implement an intervention in the light of a trial showing a certain effectiveness and cost. METHODS An individual-based model, calibrated to Zimbabwe, which incorporates effects of adherence and resistance to antiretroviral therapy, was used to model the potential impact of adherence monitoring-based interventions on viral suppression, death rates, disability adjusted life years and costs. Potential component effects of the intervention were: enhanced average adherence when on ART, reduced risk of ART discontinuation, and reduced risk of resistance acquisition. We considered a situation in which viral load monitoring is not available and one in which it is. In the former case, it was assumed that care would be differentiated based on the adherence level, with fewer clinic visits in those demonstrated to have high adherence. In the latter case, care was assumed to be primarily differentiated according to viral load level. The maximum intervention cost required to be cost effective was calculated based on a cost effectiveness threshold of $500 per DALY averted. FINDINGS In the absence of viral load monitoring, an adherence monitoring-based intervention which results in a durable 6% increase in the proportion of ART experienced people with viral load < 1000 cps/mL was cost effective if it cost up to $50 per person-year on ART, mainly driven by the cost savings of differentiation of care. In the presence of viral load monitoring availability, an intervention with a similar effect on viral load suppression was cost-effective when costing $23-$32 per year, depending on whether the adherence intervention is used to reduce the level of need for viral load measurement. CONCLUSION The cost thresholds identified suggest that there is clear scope for adherence monitoring-based interventions to provide net population health gain, with potential cost-effective use in situations where viral load monitoring is or is not available. Our results guide the implementation of future adherence monitoring interventions found in randomized trials to have health benefit.
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Affiliation(s)
- Andrew N Phillips
- Research Department of Infection & Population Health, UCL, London, United Kingdom
| | - Valentina Cambiano
- Research Department of Infection & Population Health, UCL, London, United Kingdom
| | - Fumiyo Nakagawa
- Research Department of Infection & Population Health, UCL, London, United Kingdom
| | | | - Papa Salif Sow
- Bill & Melinda Gates Foundation, Seattle, Washington, United States of America
| | - Peter Ehrenkranz
- Bill & Melinda Gates Foundation, Seattle, Washington, United States of America
| | - Deborah Ford
- Institute for Clinical Trials and Methodology, UCL, London, United Kingdom
| | | | | | | | - David R. Bangsberg
- Oregon Health Sciences University-Portland State University School of Public Health, Portland, Oregon, United States of America
| | - Paul Revill
- Centre for Health Economics, University of York, York, United Kingdom
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29
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Abstract
There are inefficiencies in current approaches to monitoring patients on antiretroviral therapy in sub-Saharan Africa. Patients typically attend clinics every 1 to 3 months for clinical assessment. The clinic costs are comparable with the costs of the drugs themselves and CD4 counts are measured every 6 months, but patients are rarely switched to second-line therapies. To ensure sustainability of treatment programmes, a transition to more cost-effective delivery of antiretroviral therapy is needed. In contrast to the CD4 count, measurement of the level of HIV RNA in plasma (the viral load) provides a direct measure of the current treatment effect. Viral-load-informed differentiated care is a means of tailoring care so that those with suppressed viral load visit the clinic less frequently and attention is focussed on those with unsuppressed viral load to promote adherence and timely switching to a second-line regimen. The most feasible approach to measuring viral load in many countries is to collect dried blood spot samples for testing in regional laboratories; however, there have been concerns over the sensitivity and specificity of this approach to define treatment failure and the delay in returning results to the clinic. We use modelling to synthesize evidence and evaluate the cost-effectiveness of viral-load-informed differentiated care, accounting for limitations of dried blood sample testing. We find that viral-load-informed differentiated care using dried blood sample testing is cost-effective and is a recommended strategy for patient monitoring, although further empirical evidence as the approach is rolled out would be of value. We also explore the potential benefits of point-of-care viral load tests that may become available in the future.
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30
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Rutstein SE, Golin CE, Wheeler SB, Kamwendo D, Hosseinipour MC, Weinberger M, Miller WC, Biddle AK, Soko A, Mkandawire M, Mwenda R, Sarr A, Gupta S, Mataya R. On the front line of HIV virological monitoring: barriers and facilitators from a provider perspective in resource-limited settings. AIDS Care 2015; 28:1-10. [PMID: 26278724 DOI: 10.1080/09540121.2015.1058896] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Scale-up of viral load (VL) monitoring for HIV-infected patients on antiretroviral therapy (ART) is a priority in many resource-limited settings, and ART providers are critical to effective program implementation. We explored provider-perceived barriers and facilitators of VL monitoring. We interviewed all providers (n = 17) engaged in a public health evaluation of dried blood spots for VL monitoring at five ART clinics in Malawi. All ART clinics were housed within district hospitals. We grouped themes at patient, provider, facility, system, and policy levels. Providers emphasized their desire for improved ART monitoring strategies, and frustration in response to restrictive policies for determining which patients were eligible to receive VL monitoring. Although many providers pled for expansion of monitoring to include all persons on ART, regardless of time on ART, the most salient provider-perceived barrier to VL monitoring implementation was the pressure of work associated with monitoring activities. The work burden was exacerbated by inefficient data management systems, highlighting a critical interaction between provider-, facility-, and system-level factors. Lack of integration between laboratory and clinical systems complicated the process for alerting providers when results were available, and these communication gaps were intensified by poor facility connectivity. Centralized second-line ART distribution was also noted as a barrier: providers reported that the time and expenses required for patients to collect second-line ART frequently obstructed referral. However, provider empowerment emerged as an unexpected facilitator of VL monitoring. For many providers, this was the first time they used an objective marker of ART response to guide clinical management. Providers' knowledge of a patient's virological status increased confidence in adherence counseling and clinical decision-making. Results from our study provide unique insight into provider perceptions of VL monitoring and indicate the importance of policies responsive to individual and environmental challenges of VL monitoring program implementation. Findings may inform scale-up by helping policy-makers identify strategies to improve feasibility and sustainability of VL monitoring.
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Affiliation(s)
- S E Rutstein
- a Department of Health Policy and Management , University of North Carolina at Chapel Hill , Chapel Hill , NC , USA.,b Department of Medicine , University of North Carolina at Chapel Hill , Chapel Hill , NC , USA
| | - C E Golin
- c Department of Health Behavior , University of North Carolina at Chapel Hill , Chapel Hill , NC , USA
| | - S B Wheeler
- a Department of Health Policy and Management , University of North Carolina at Chapel Hill , Chapel Hill , NC , USA
| | | | - M C Hosseinipour
- b Department of Medicine , University of North Carolina at Chapel Hill , Chapel Hill , NC , USA.,d UNC Project , Lilongwe , Malawi
| | - M Weinberger
- a Department of Health Policy and Management , University of North Carolina at Chapel Hill , Chapel Hill , NC , USA
| | - W C Miller
- b Department of Medicine , University of North Carolina at Chapel Hill , Chapel Hill , NC , USA.,e Department of Epidemiology , University of North Carolina at Chapel Hill , Chapel Hill , NC , USA
| | - A K Biddle
- a Department of Health Policy and Management , University of North Carolina at Chapel Hill , Chapel Hill , NC , USA
| | - A Soko
- d UNC Project , Lilongwe , Malawi
| | - M Mkandawire
- f School of Public Health , Loma Linda University , Loma Linda , CA , USA
| | - R Mwenda
- g Ministry of Health , Lilongwe , Malawi
| | - A Sarr
- h Centers for Disease Control , Lilongwe , Malawi
| | - S Gupta
- h Centers for Disease Control , Lilongwe , Malawi
| | - R Mataya
- f School of Public Health , Loma Linda University , Loma Linda , CA , USA
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31
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Boender TS, Hoenderboom BM, Sigaloff KCE, Hamers RL, Wellington M, Shamu T, Siwale M, Labib Maksimos EEF, Nankya I, Kityo CM, Adeyemo TA, Akanmu AS, Mandaliya K, Botes ME, Ondoa P, Rinke de Wit TF. Pretreatment HIV drug resistance increases regimen switches in sub-Saharan Africa. Clin Infect Dis 2015; 61:1749-58. [PMID: 26240203 DOI: 10.1093/cid/civ656] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2015] [Accepted: 07/23/2015] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND After the scale-up of antiretroviral therapy (ART) for human immunodeficiency virus (HIV) infection in Africa, increasing numbers of patients have pretreatment drug resistance. METHODS In a large multicountry cohort of patients starting standard first-line ART in six African countries, pol genotyping was retrospectively performed if viral load (VL) ≥1000 cps/mL. Pretreatment drug resistance was defined as a decreased susceptibility to ≥1 prescribed drug. We assessed the effect of pretreatment drug resistance on all-cause mortality, new AIDS events and switch to second-line ART due to presumed treatment failure, using Cox models. RESULTS Among 2579 participants for whom a pretreatment genotype was available, 5.5% had pretreatment drug resistance. Pretreatment drug resistance was associated with an increased risk of regimen switch (adjusted hazard ratio [aHR] 3.80; 95% confidence interval [CI], 1.49-9.68; P = .005) but was not associated with mortality (aHR 0.75, 95% CI, .24-2.35; P = .617) or new AIDS events (aHR 1.06, 95% CI, .68-1.64; P = .807). During three years of follow up, 106 (4.1%) participants switched to second-line, of whom 18 (17.0%) switched with VL < 1000 cps/mL, 7 (6.6%) with VL ≥ 1000 cps/mL and no drug resistance mutations (DRMs), 46 (43.4%) with VL ≥ 1000 cps/mL and ≥1 DRMs; no HIV RNA data was available for 32 (30.2%) participants. CONCLUSIONS Given rising pretreatment HIV drug resistance levels in sub-Saharan Africa, these findings underscore the need for expanded access to second-line ART. VL monitoring can improve the accuracy of failure detection and efficiency of switching practices.
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Affiliation(s)
- T Sonia Boender
- Amsterdam Institute for Global Health and Development and Department of Global Health
| | - Bernice M Hoenderboom
- Amsterdam Institute for Global Health and Development and Department of Global Health
| | - Kim C E Sigaloff
- Amsterdam Institute for Global Health and Development and Department of Global Health Department of Internal Medicine, Division of Infectious Diseases, Academic Medical Center of the University of Amsterdam, The Netherlands
| | - Raph L Hamers
- Amsterdam Institute for Global Health and Development and Department of Global Health Department of Internal Medicine, Division of Infectious Diseases, Academic Medical Center of the University of Amsterdam, The Netherlands
| | | | | | | | | | | | | | - Titilope A Adeyemo
- Department of Haematology and Blood Transfusion, University of Lagos, Nigeria University Teaching Hospital, Nigeria
| | - Alani Sulaimon Akanmu
- Department of Haematology and Blood Transfusion, University of Lagos, Nigeria University Teaching Hospital, Nigeria
| | | | | | - Pascale Ondoa
- Amsterdam Institute for Global Health and Development and Department of Global Health
| | - Tobias F Rinke de Wit
- Amsterdam Institute for Global Health and Development and Department of Global Health
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32
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Sigaloff KCE, de Wit TFR. ART in sub-Saharan Africa: the value of viral load monitoring. Lancet HIV 2015; 2:e261-2. [PMID: 26423247 DOI: 10.1016/s2352-3018(15)00109-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2015] [Accepted: 05/27/2015] [Indexed: 11/17/2022]
Affiliation(s)
- Kim C E Sigaloff
- Amsterdam Institute for Global Health and Development, Department of Global Health, Academic Medical Center, University of Amsterdam, 1100 DE Amsterdam, Netherlands; Department of Internal Medicine, Division of Infectious Diseases, Academic Medical Center, University of Amsterdam, 1100 DE Amsterdam, Netherlands.
| | - Tobias F Rinke de Wit
- Amsterdam Institute for Global Health and Development, Department of Global Health, Academic Medical Center, University of Amsterdam, 1100 DE Amsterdam, Netherlands
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