Centre for Infectious Disease Epidemiology and Research, Department of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, South Africa.
S Afr Med J. 2019 Feb 26;109(3):174-177. doi: 10.7196/SAMJ.2019.v109i3.13456.
The Joint United Nations Programme on HIV/AIDS (UNAIDS) third 90-90-90 target requires 90% of patients on antiretroviral treatment (ART) to be virally suppressed (<1 000 copies/mL). In Khayelitsha, Cape Town, South Africa viral load (VL) suppression of <400 copies/mL was reported as 89% in 2016, but only 56% of patients had a result recorded in routine data. We conceived a VL 'cascade' to represent the steps required for an expected VL to be reported as complete in routine data and thus contribute to reported VL suppression: among those for whom a VL is 'expected', a sample must be collected and tested ('done'), a result must be 'filed' in the patient folder, 'noted' by a clinician and electronically 'captured'. The low reported completion suggested gaps along the VL cascade and cast doubt on the validity of reported suppression.
To assess the validity of routinely reported VL suppression and identify barriers to VL completion.
A retrospective cohort study between 1 July 2015 and 30 June 2016, which included all Khayelitsha patients receiving ART, with a routine VL expected, was conducted. We obtained data routinely captured on site and VL data from the laboratory system. A sample of 1 035 patient folders was reviewed. VL suppression was calculated using laboratory data, including all tests done, and compared with reported suppression based on on-site captured electronic data. Successful progression through each step on the VL cascade was estimated. We used logistic regression to identify factors associated with laboratory data and reported VL testing.
Of 22 991 patients for whom a routine VL test was due, 84% were done, 79% filed, 76% noted and 55% captured. Using all laboratory data, VL suppression was estimated as 82%, 87%, 89% and 91% at the 50, 200, 400 and 1 000 copies/mL thresholds, respectively, but reported suppression using captured results was 80%, 86%, 88% and 89% at those thresholds. Routine VL testing is more likely to be done in children <15 years old (adjusted odds ratio (aOR) 1.89, 95% confidence interval (CI) 1.45 - 2.48) and pregnant women (aOR 1.90, 95% CI 1.28 - 2.81) than in men, adjusted for facility.
Despite a low reported completion, VL testing completion was high. Reported suppression using captured data was similar to suppression calculated using all laboratory data, which provided an accurate measure of progress towards the 90-90-90 target. More work is needed to reach the 16% of patients missed by routine testing.
联合国艾滋病规划署（UNAIDS）的第三个 90-90-90 目标要求 90%接受抗逆转录病毒治疗（ART）的患者病毒得到抑制（<1000 拷贝/毫升）。在南非开普敦的 Khayelitsha，2016 年报告的病毒载量（VL）抑制率为 <400 拷贝/毫升，达到 89%，但只有 56%的患者在常规数据中有记录结果。我们设想了一个 VL“级联”，以代表报告常规数据中完全的 VL 所需的步骤，从而有助于报告 VL 抑制：对于那些预计 VL 的患者，必须采集并检测样本（“完成”），结果必须在患者文件夹中“归档”，由临床医生“记录”并在电子病历中“捕获”。低报告完成率表明 VL 级联中存在差距，并对报告抑制的有效性产生怀疑。
评估常规报告的 VL 抑制率的有效性，并确定 VL 完成的障碍。
2015 年 7 月 1 日至 2016 年 6 月 30 日期间，对所有在 Khayelitsha 接受 ART 治疗且预计有常规 VL 的患者进行了回顾性队列研究。我们获得了现场常规捕获的数据和实验室系统中的 VL 数据。对 1035 份患者文件夹进行了审查。使用实验室数据（包括所有进行的检测）计算 VL 抑制率，并与基于现场捕获的电子数据报告的抑制率进行比较。估计 VL 级联中每个步骤的成功进展情况。我们使用逻辑回归来确定与实验室数据和报告的 VL 检测相关的因素。
在 22991 名预计进行常规 VL 检测的患者中，84%的患者进行了检测，79%的患者进行了归档，76%的患者进行了记录，55%的患者进行了电子捕获。使用所有实验室数据，VL 抑制率分别为 50、200、400 和 1000 拷贝/毫升时估计为 82%、87%、89%和 91%，但使用捕获结果报告的抑制率分别为 80%、86%、88%和 89%。与男性相比，儿童 <15 岁（调整后的优势比（aOR）1.89，95%置信区间（CI）1.45-2.48）和孕妇（aOR 1.90，95%CI 1.28-2.81）更有可能进行常规 VL 检测，这是对设施进行调整后的结果。
尽管报告完成率较低，但 VL 检测完成率较高。使用捕获数据报告的抑制率与使用所有实验室数据计算的抑制率相似，这为实现 90-90-90 目标提供了一个准确的进展衡量标准。还需要做更多的工作来覆盖常规检测遗漏的 16%的患者。
