Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, South Africa; Department of Infectious Diseases, Nelson R Mandela School of Medicine, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa.
S Afr Med J. 2021 Mar 31;111(4):299-303. doi: 10.7196/SAMJ.2021.v111i4.15432.
Identification of patients on antiretroviral therapy (ART) with virological failure (VF) and the response in the public health sector remain significant challenges. We previously reported improvement in routine viral load (VL) monitoring after ART commencement through a health system-strengthening, nurse-led 'VL champion' programme as part of a multidisciplinary team in three public sector clinics in Durban, South Africa.
To report on the impact of the VL champion model adapted to identify, support and co-ordinate the management of individuals with VF on first-line ART in a setting with limited electronic-based record capacity.
We evaluated the VL champion model using a controlled before-after study design. A paper-based tool, the 'high VL register', was piloted under the supervision of the VL champion to improve data management, monitoring of counselling support, and enacting of clinical decisions. We abstracted chart and electronic data (TIER.net) for eligible individuals with VF in the year before and after implementation of the programme, and compared outcomes for individuals during these periods. Our primary outcome was successful completion of the VF pathway, defined as a repeat VL <1 000 copies/mL or a change to second-line ART within 6 months of VF. In a secondary analysis, we assessed the completion of each step in the pathway.
We identified 60 and 56 individuals in the pre-intervention and post-intervention periods, respectively, with VF who met the inclusion criteria. Sociodemographic and clinical characteristics were similar between the periods. Repeat VL testing was completed in 61.7% and 57.8% of individuals in these two groups, respectively. We found no difference in the proportion achieving our primary outcome in the pre- and post-intervention periods: 11/60 (18.3%; 95% confidence interval (CI) 9 - 28) and 15/56 (22.8%; 95% CI 15 - 38), respectively (p=0.28). In multivariable logistic regression models adjusted for potential confounding factors, individuals in the post-intervention period had a non-significant doubling of the odds of achieving the primary outcome (adjusted odds ratio 2.07; 95% CI 0.75 - 5.72). However, there was no difference in the rates of completion of each step along the first-line VF cascade of care.
This enhanced intervention to improve VF in the public sector using a paper-based data management system failed to achieve significant improvements in first-line VF management over the standard of care. In addition to interventions that better address patient-centred factors that contribute to VF, we believe that there are substantial limitations to and staffing requirements involved in the ongoing utilisation of a paper-based tool. A prioritisation is needed to further expand and upgrade the electronic medical record system with capabilities for prompting staff regarding patients with missed visits and critical laboratory results demonstrating VF.
在接受抗逆转录病毒疗法 (ART) 的患者中识别出病毒学失败 (VF) 患者，以及在公共卫生部门的反应仍然是一个重大挑战。我们之前报告过，在南非德班的三个公立部门诊所中，通过一个强化卫生系统、由护士领导的“病毒载量冠军”计划，作为多学科团队的一部分，ART 开始后常规病毒载量 (VL) 监测得到了改善。
报告适应识别、支持和协调一线 ART 中 VF 个体管理的 VL 冠军模型的影响，该模型适用于电子记录能力有限的环境。
我们使用对照前后研究设计评估了 VL 冠军模型。在 VL 冠军的监督下，我们使用纸质工具“高 VL 登记册”进行了试点，以改善数据管理、监测咨询支持和实施临床决策。我们在该方案实施前后的一年中，为 VF 的合格个体提取图表和电子数据 (TIER.net)，并比较这些时期个体的结果。我们的主要结局是成功完成 VF 途径，定义为重复 VL <1000 拷贝/毫升或在 VF 后 6 个月内改变二线 ART。在二次分析中，我们评估了途径中每个步骤的完成情况。
我们分别在干预前和干预后时期确定了 60 名和 56 名 VF 符合纳入标准的个体。在这两个时期，社会人口统计学和临床特征相似。这两组分别有 61.7%和 57.8%的个体完成了重复 VL 检测。我们发现干预前后两组达到主要结局的比例没有差异：11/60 (18.3%；95%置信区间 (CI) 9-28)和 15/56 (22.8%；95% CI 15-38)，分别 (p=0.28)。在调整潜在混杂因素的多变量逻辑回归模型中，干预后组达到主要结局的可能性增加了一倍，但无统计学意义 (调整后的优势比 2.07；95% CI 0.75-5.72)。然而，一线 VF 级联护理中每个步骤的完成率没有差异。
使用纸质数据管理系统，本项旨在增强公共部门 VF 干预的工作，并未在一线 VF 管理方面取得优于常规护理的显著改善。除了干预措施之外，我们认为，持续使用纸质工具涉及到患者为中心的因素，存在实质性限制和人员配备需求。需要优先考虑进一步扩大和升级具有提示员工有关错过就诊和表明 VF 的关键实验室结果的电子病历系统的功能。
