1. Utilizing research as an opportunity to strengthen
the Health System in rural KwaZulu-Natal.
Janet Michel1, Katharine Stott1,Tulio de Oliveira1, Colin Newell1, Marie-Louise Newell1,2
1. Africa Centre for Health and Population Studies, University of KwaZulu-Natal, South Africa
2. Faculty of Medicine, University of Southampton, United Kingdom                                                       
INTRODUCTION
The rapid scale-up of antiretroviral therapy (ART) has led to dramatic reductions in HIV-related morbidity and mortality. Focus is now on maintaining virologic suppression, detecting treatment failure and switching to second-line regimens where necessary. In Southern Africa, routine viral-load monitoring is recommended 6 months from initiation and annually thereafter. However, it is often not done with sufficient frequency, nor reacted to appropriately [1]. Since 2004, Hlabisa HIV Treatment and Care Programme has provided care and clinical mentoring to 17 primary healthcare clinics (PHC) in Hlabisa. The Africa Centre-based ART monitoring and evaluation database revealed that viral load monitoring in the clinics was not being done according to the current South African guidelines [2].
RESULTS
Finding 1
All ART nurses (n=40) reported being unaware of the importance of viral load monitoring post-ART initiation and were much more concerned about CD4 count, although a copy of the new South African ART guidelines was available in every facility. Guidelines are not necessarily read or followed in clinical management.
Finding 2
After the teaching intervention, the number of overdue viral loads (viral loads not done when they were due as per SA guidelines) per PHC decreased by an average of 50% within three months.
Figure 1. Overdue viral loads per clinic
Finding 3
The number of patients referred for assessment of HIV drug resistance (HIV genotyping) more than doubled on average, leading to improved patient outcomes.
Figure 2. HIV genotyping reports
AIMS AND OBJECTIVES
The goal of ART is to reduce morbidity and mortality and improve quality of life through durable suppression of viral replication and restoration of immunologic function [2].
Objective
To explore the reasons for the lack of routine viral-load monitoring, as recommended in the South African ART guidelines to identify treatment failure
Significance
Sustained suppression of viral load levels is associated with reduced HIV-related morbidity and mortality and a lower probability of sexual transmission of HIV.
METHODS
Data was obtained from two sources: the Africa Centre hosted HIV Treatment database - a rich HIV clinical and laboratory data resource relating to all people accessing HIV treatment and care in Hlabisa sub-district - and additional information from PHC clinical mentoring visits. Routine ART monitoring reports showed that many patients on ART were not evaluated for viral load as per guidelines.
Two researchers designed a flow-chart which followed South African Clinical guidelines and used this for one-on-one teaching sessions with all ART nurses during routine PHC mentoring visits. ART data on the number of patients overdue for viral load measurement was collected from the ART database in July 2012 before the intervention and again in October to assess the effect of the teaching intervention.
RESEARCH AS AN OPPORTUNITY TO STRENGTHEN THE HEALTH SYSTEM
Data collection for research purposes
Gaps identified in database during collection, cleaning collating and analysis
Researchers refer to DoH standards and guidelines
Researchers provide on site, on the job capacity building of health workers.
Acknowledgments
We would like to thank the Hlabisa Management, PHC Supervisors, managers and staff of the 17 clinics in Hlabisa sub district for their time and insights. We are also grateful for the generous support of the Wellcome Trust for the core funding of the Africa Centre and the American people through the United States Agency for International Development (USAID) and the President’s Emergency Plan for AIDS Relief (PEPFAR) under the terms of award no. 674-A for funding to the HIV Treatment and Care Programme.
References
Stott K, Michel J, de Oliveira T.. Principles of HIV drug resistance for clinical management in South Africa .HIV Nursing Matters,3(4):46-51 (2012)
The South African Antiretroviral Treatment Guidelines Department of Health. Republic of South Africa.
Maenza J & Flexner C. Combination antiretroviral therapy for HIV infection. Fam Physician. 1998 Jun; 57(11):
CONCLUSIONS
Research facilitates identification of gaps between policy and practice. Reference to standards and guidelines by researchers and direct capacity-building of health personnel based on identified gaps could be a basis for ethical research as well as an opportunity for researchers to strengthen the health system.