Making Viral Load Monitoring Routine within ART programmes Presented by Dr.Henry Sunpath MEDICATE – AIDS NPC Consultant ETHEKWINI HIVVL&DR PROJECT CAPRISA ACC PROGRAM on behalf of the TEAM Kogie Naidoo, Rochelle Adams, Kevi Naidu, Penny Msimango,Mary Mogashoa 07 September 2018
Background • Since 2014, the landscape of HIV patient monitoring has changed VL testing has replaced CD4 for monitoring Antiretroviral treatment response • Low uptake of routine VL testing despite policy and access • <40% VL testing coverage since 2014 among eligible patients • Lack of awareness among patients and HCW • Insufficient systems at facility level to ensure regular and timed testing
Question 1 • What are the key steps in a quality improvement program A. Root cause analysis and ongoing education and development B. Root cause analysis and stakeholder strategy C. Root cause analysis ,stakeholder strategy and ongoing education and development
Q2.Define VL completion rate • Proportion of adults in the 12 month cohort, still on treatment who had Viral load test done in the last year • Proportion of adults in the 12 months cohort who should have been on treatment who had a VL test done in the last year
Q3.When is the repeat Vl done after the first high VL >1000 copies/ml • 1. Visit 2 • 2.Visit 3 • 3. Visit 4
Q4. Which intervention will impact most on the reporting of VL completion rate • 1. NHLS reports • 2. Improving entry of VL results onto clinical charts • 3. Ensuring that data capturing takes place daily • 4. Triangulation of NHLS – clinical records in the charts and Tier data • 5. None of the above
Q5.Which factor affects the Tier recording of VL data most adversely • 1. Problems with the computers • 2. Problems with the data capturers • 3. Poor records in the clinical charts • 4.NHLS failure to provide results timeously
Q6. Which steps are needed on a list of quick wins to rapidly improve VL completion rates • 1. Ownership of the VL monitoring process – appoint a VL champ • 2. Institute the VL anniversary concept • 3. Demand creation by patient education and staff education • 4.Pharmacy gate keeping not to issue ART for more than one month without a VL result • 6.Use of appointment cards • 7. All of the above • 8.All except 4
Quality improvement model Ongoing Root cause Stakeholder education and analysis (SIMS) strategy development
Interlinked Unique Identifier, electronic Biometrics systems DBS/ POC Source: Ms Linda Dlamini , KZN ART Manager , 28 May 2018
1. Know your 2. Target setting 3. Data 4. indicator, track and targeting management Communication your response, (ACSM, demand Bottleneck Analysis 3X4 Matrix accountability creation strategy) Quality of care 6 Infrastructure, 7. Human 8. Service medicines, resources delivery equipment, lab (quantity, platforms (incl services capacity and WBOT's and skills) mobile services) 9. Demand: 10. Cascades and 11. Demand: 12. Inter-sectoral Service delivery pathways Client related coordination related (continuum of (social care) development, private sector, schools)
Adult with Viral load completion (VLD) rate (HIV -8) Definition: • Proportion of adults in the 12 month cohort, still on treatment who had Viral load test done in the last year Numerator: • Adult viral load done (VLD) at 12 months Denominator: • Adult first line regimen + Adult second line regimen at intervals in 12 month cohort 2016/17 Target (Proposed): • 80 % VLD rate at 12 months
Key clinical contact points – ensure activity • Clinical Assessment Visit 1 • Management Plan / Enhanced Adherence • UTT and ART initiation Linkage to Care Visit 2 • Review of issues addressed by management At 1 month plan 6 months • VL<400 post ART • VL>1000 initiation Visit 3 • Repeat VL • Review of At 2 months Progress • VL<400 1 year post • VL 400-1000 ART initiation • VL>1000 Visit 4 Review of repeat VL
Root cause analysis – summary- PHC • LOW stats reported for VLD due to Missed appointments ,delayed reporting to clinics, lack of blood draws due to Poor patient education and health worker investment due to Due to high volume clinics and poor role differentiation of staff due to Lack of ownership of responsibility for Vl monitoring • Acting on results not according to SOC due to No dedicated persons and systems to engage pts with high VL due to Lack of staff orientation to protocols due to Lack of training and supervision of NIMART nurses and junior doctors
TIER.NET Challenges Poor data management due to Incomplete entry of data onto clinical charts Ill defined data flow within facility HR issues and equipment issues 1. Facility Data Captures not working as much as they are supposed to. 2. Backlogs-There is a big number of files in backlog resulting in the increased number of defaulters. 3. Broken Computers in our facilities. (Technicians takes too long to respond to facilities whenever they report broken computers) Three data sources not complementary
VL Health Information Systems Tier.net Clinical NHLS Chart
Analysis of various sources of VL data- • Very large numbers of Vl tests done monthly – are they appropriately done and acted upon • Are repeat VL being done and acted upon after VF and adherence intervention? • NHLS unable to report on VL completion rates • What is the best way to assess the VL completion rates ? 1. Need to triangulate data between NHLS database – Tier.net – clinical charts in the catch up phase 2. Need to ensure that VL completion rate is accurately documented in real time
• QIP – CAPRISA ACC :B :BASELINE ANALYSIS • IMPLEMENTATION OF QIP BASED ON ROOT CAUSE ANALYSIS • PILOT SITE IMPLEMENTATION • UPSCALE TO OTHER SITES
CAPRISA ACC – Random file and facility audit 2016 (11 Ethekwini sites) Viral Viral Load Suppression 100 92.2 Coverage in Rates in 88.8 89.8 (703/762) Adult and Adults and 485/546) (327/364) 90 Paediatric Children 79.3 patients (23/29) 80 70 68.2 (7/10) (15/22) 70 60 Percentage 50 41.7 (762/1826) 36.3 40 (29/80) 32.1 29.3 (546/1701) (22/75) 25.9 30 (364/1403) 19.6 (10/51) 20 10 0 Viral Load Viral Load Viral Supression Viral Supression Conducted Conducted (Adults) (Peads) (Adults) (Peads) 6 months 12 months 24 Months
Problem statement: Low Viral Load Coverage & Poor identification of ART failure Two/more Consecutive Unsuppresse d Viral Loads ACC File and Facility Review in KZN
STEPS TO ACHIEVE THE IDEAL HIV-VL&DR MONITORING PROGRAM – ART CLINIC LEVEL 1. HAST CLINICAL MANAGER AND VL Terms of reference identified for overall supervision of process Responsible for CHAMP in each CHC/hospital and VLC facility reports to DOH in each ART site assisted by QA teams Manage exit plan with partners in 2018 so that M&E takes over. 2. MAKE VIRAL LOAD MONITORING 1. INCREASE DEMAND BY PT EDUCATION AND HCW EDUCATION ROUTINE 2. INSTITUTE VL ANIVERSARY CONCEPT 3. IMPLEMENT GATE KEEPING NOT TO ISSUE REPEAT SCRIPTS WITHOUT VL 3. SYNERGISE DATA SOURCES SO THAT 1. ENSURE THAT VL RESULTS ARE ENTERED INTO CLINICAL CHARTS DAILY SO TIER.NET IS OPTIMALLY FUNCTIONAL THAT TIER.NET CAN BE UPDATED . AND TOTALLY RELIABLE 2. CATCH UP PHASE TO ACCOUNT FOR EVERY PATIENT EVER SEEN IN CLINIC AND NOT ACCOUNTED FOR ON TIER.NET. FINALLY DEPEND ON TIER REPORTS ONLY.-AUDIT OF ENTIRE FILE REGISTRY 3. CREATE A HIGH VL REGISTER FOR IST AND 2 ND LINE ART FROM ALL DATA SOURCES – ROUTINE CLINIC VL RECORDS , NHLS WEEKLY DASHBOARD, TIER.NET RECORDS, PHARMACY RECORDS , COMPLETE FILE AUDIT OF ALL ACTIVE PATIENTS. 4. START VL PRIORITY CLINIC ON 1. Trained EAC team work with trained doctor to manage complex VF in first SPECEFIC DAY/ DEDICATED TEAM line and all second line VF WORKING DAILY 2. Ensure that all patients receive care by a MDT 5. SUPPORT PHCs in the area 1. VLC in each PHC to be mentored and supported by local CHC/hospital .Manage all first line VF and refer all second line VF Standardise referral forms for VF and data required for 3 RD line ART 2.
DEVELOPMENT OF SOPs and TOOLS • Making Vl monitoring routine • Management of FLART failure – with algorithim and flow charts • Management of SLART failure – with algorithim and flow chart • Application for TLART- clinical management and drug supply chain • Roles and responsibilities of clinic teams • Logistical arrangement of services within the district • Registers : Baseline file audit log; Vl sample log ; High Vl register for FLART &SLART • Tools – Adherence checklist and enhanced adherence counselling tool (NDOH)
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