A packaged intervention to improve viral load monitoring within a deeply rural health district of South Africa

Abstract

Background: The KwaZulu-Natal (KZN) province of South Africa has the highest prevalence of HIV infection in the world. Viral load (VL) testing is a crucial tool for clinical and programmatic monitoring. Within uMkhanyakude district, VL suppression rates were 91% among patients with VL data; however, VL performance rates averaged only 38·7%. The objective of this study was to determine if enhanced clinic processes and community outreach could improve VL monitoring within this district.

Methods: A packaged intervention was implemented at three rural clinics in the setting of the KZN HIV AIDS Drug Resistance Surveillance Study. This included file hygiene, outreach, a VL register and documentation revisions. Chart audits were used to assess fidelity. Outcome measures included percentage VL performed and suppressed. Each rural clinic was matched with a peri-urban clinic for comparison before and after the start of each phase of the intervention. Monthly sample proportions were modelled using quasi-likelihood regression methods for over-dispersed binomial data.

Results: Mkuze and Jozini clinics increased VL performance overall from 33·9% and 35·3% to 75·8% and 72·4%, respectively which was significantly greater than the increases in the comparison clinics (RR 1·86 and 1·68, p < 0·01). VL suppression rates similarly increased overall by 39·3% and 36·2% (RR 1·84 and 1·70, p < 0·01). The Chart Intervention phase showed significant increases in fidelity 16 months after implementation.

Conclusions: The packaged intervention improved VL performance and suppression rates overall but was significant in Mkuze and Jozini. Larger sustained efforts will be needed to have a similar impact throughout the province.

Keywords: HIV; Monitoring; Rural health; South Africa; Viral load; Virologic suppression.

Fig. 1

Time Line for Packaged Intervention. The first observation period, Study Implementation, began in January 2014, 6 months before initiation (yellow line) of the KwaZulu-Natal HIV Drug Resistance Surveillance Study (DReSS) and ended in December 2014 prior to when participants were due for their first HIV-1 viral load (first red dashed line). During this period, DReSS nurses assisted with clinic blood draws and maintained the study participant clinic files in a secure location. The second observation period, Study Steady State, began in January 2015 and ended in June 2015 (second red dashed line). Outreach phone calls and visits began during this period to assist in obtaining blood samples for viral loads. The final observation period, Chart Intervention, began in July 2015 at the time of the first chart audit (green bar) and ended in July 2017 several months after the second chart audit (yellow bar). This period included improvements in chart documentation and the introduction of the viral load register. DReSS completed the final follow up visit in July 2018 (blue line)

Fig. 2

Temporal Trends in Virologic Suppression and Completion within each clinic. Virologic Suppression (a-c) and Viral Load Completion (d-f) percentages over the three phases of the study are represented for the District Hospitals, Bethesda CDC and RK Khan (a and d) and four Primary Health Clinics, Mkhuze and Shallcross (b and e) and Jozini and Township Center (c and f). Rural clinics are shown in green with the peri-urban clinics shown in black. The first period, Study Implementation, ends with the first red dashed line. The second period, Study Steady State, begins with the first red dashed line and ends with the second red dashed line. The third period, Chart Intervention, begins with the second red dashed line. The horizontal black dashed line denotes the 90% goal