Mark Nsumba Steven, Rachel Musomba, Kaimal Arvind, Frank Mubiru, Harriet Tibakabikoba, Isaac Lwanga, Lamorde Mohammed, Barbara Castelnuovo
Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda.
AIDS Res Treat. 2019 Dec 15;2019:9271450. doi: 10.1155/2019/9271450. eCollection 2019.
To describe the clinical decisions taken for patients failing on treatment and possible implementation leakages within the monitoring cascade at a large urban HIV Centre in Kampala, Uganda.
As per internal clinic guidelines, VL results >1,000 copies/ml are flagged by a quality assurance officer and sent to the requesting clinician. The clinician fills a "decision form" choosing: (1) refer for adherence counselling, (2) repeat VL after 3 months, and (3) switch to second line. We performed data extraction on a random sample of 100 patients with VL test >1,000 copies/ml between January and August 2015. For each patient, we described the action taken by the clinicians.
Of 6,438 patients with VL performed, 1,021 (16%) had >1,000 copies/ml. Of the 100 (10.1%) clinical files sampled, 61% were female, median age was 39 years (IQR: 32-47), 81% were on 1-line ART, 19% on 2-line, median CD4 count was 249 cells/L (IQR: 145-390), median log VL 4.42 (IQR: 3.98-4.92). Doctors' decisions were; refer for adherence counseling 49%, repeat VL for 25%, and switch to second line for 24% patients. Forty-one percent were not managed according to the guidelines. Of these, 29 (70.7%) were still active in care, 7 were tracked [5 (12.2%) lost to program, 2 (4.9%) dead] and 5 patients were not tracked.
Despite the implementation of internal systems to manage patients failing ART, we found substantial leakages in the monitoring "cascade". Additional measures and stronger clinical supervision are needed to make every test count, and to ensure appropriate management of patients failing on ART.
描述乌干达坎帕拉一家大型城市艾滋病病毒中心针对治疗失败患者所做出的临床决策以及监测环节中可能存在的实施漏洞。
根据内部诊所指南，病毒载量（VL）结果>1000拷贝/毫升时，质量保证官员会标记出来并发送给申请检测的临床医生。临床医生填写一份“决策表”，选择：（1）转介接受依从性咨询，（2）3个月后复查病毒载量，（3）换用二线治疗。我们对2015年1月至8月期间病毒载量检测>1000拷贝/毫升的100例患者的随机样本进行了数据提取。对于每位患者，我们描述了临床医生采取的行动。
在进行病毒载量检测的6438例患者中，1021例（16%）病毒载量>1000拷贝/毫升。在抽取的100份（10.1%）临床档案中，61%为女性，中位年龄为39岁（四分位间距：32 - 47岁）；81%接受一线抗逆转录病毒治疗（ART），19%接受二线治疗；中位CD4细胞计数为249个/微升（四分位间距：145 - 390个/微升），中位病毒载量对数为4.42（四分位间距：3.98 - 4.92）。医生的决策为：49%的患者转介接受依从性咨询，25%的患者复查病毒载量，24%的患者换用二线治疗。41%的患者未按照指南进行管理。其中，29例（70.7%）仍在接受治疗，7例得到追踪[5例（12.2%）失访，2例（4.9%）死亡]，5例患者未得到追踪。
尽管实施了内部系统来管理抗逆转录病毒治疗失败的患者，但我们发现监测“环节”中存在大量漏洞。需要采取额外措施并加强临床监督，以使每次检测都有意义，并确保对抗逆转录病毒治疗失败的患者进行适当管理。
