HIV/AIDS treatment

HIV/AIDS treatment

Scaling up antiretroviral therapy (ART) for HIV/AIDS is a challenge for countries with limited resources and with many other health priorities to tackle. This is especially true when the goal is to achieve full treatment coverage of an increasing number of AIDS patients who require a life long coverage of services. This brings to the fore the need for a strong management information system to monitor and evaluate efficiency and effectiveness of ART programmes.

I can assist with monitoring and evaluation of ART programmes. This includes the overview and update of the whole chain of events underlying ART management, including counseling and testing sessions, assignment to ART regimens, monitoring the side effects and the opportunistic infections, update changes in treatment regimes, recording default and mortality.

I can also fully exploit the data coming from the ART management information system to identify effectiveness factors that are critical for a sustainable scale up of ART. This is important to identify those factors that make a difference in improving effectiveness and that can be changed through management.

Examples include:

(a) I provided technical assistance to the Department of Health of KwaZulu-Natal (KZN), South Affrica,  in monitoring the performance of the ART management. This included the monitoring of the weekly numbers of people undergoing HIV counseling and testing, being under the CD4 cut off point to be eligible for ART, initiating a treatment regimen, coming back for follow up, having side effects, defaulting and dying. The data,which were provided by the ART clinics every week, were critically assessed for reliability, problems were spotted and relevant clinics were contacted to correct errors.

(b) I conducted operational research in the field of ART of HIV/AIDS patients in KZN. The objective was to identify the factors related to the patients and to the clinic sites that were significant predictors of mortality and default. A retrospective analysis on the first two years of treatment was carried out on the data obtained from all the 32 clinics that were distributing ART in KZN. Besides the patients' information that was available from the ART management information system, survey teams collected data on the clinics' infrastructure, staffing, accessibility to the site and crowding, availability of drugs, waiting time to receive laboratory results and other characteristics that could have influenced treatment outcomes. A task analysis recorded staff and patients' interactions and compliance with guidelines.

At parity of other significant factors, the number of annual new patients per staff was significantly associated with patients' retention. This allowed to identify the probability of remaining on ART at the end of two years of treatment for patients attending clinics where the workload was <100, 100-199, and 200+ new patients per medical doctor per year. This was critical in identifying clinic sites which had a higher risk of loosing patients and in defining alternative management strategies that were associated with different probabilities of retaining patients. A Monte Carlo simulation allowed to estimate the robustness of the predictions that such strategies would have had on patients' retention and to estimate the relative incremental cost effectiveness ratios.

(c) I provided technical assistance to the DOH of KZN in monitoring HIV resistance to ART. As ART is used by an increasing number of patients who might not always comply with treatment schedule, ART resistance might develop, threatening its effectiveness. The survey included samples of antenatal care attendees who were not under ART and met the survey's selection criteria proposed by WHO guidelines. Genotyping revealed a prevalence of HIV drug resistant strains of less than 5%, which is the cut off point used by WHO to define low prevalence of ART resistance in newly diagnosed HIV cases.