Acceptability of point-of-care viral load testing to facilitate differentiated care: a qualitative assessment of people living with HIV and nurses in South Africa

Lindani Msimango, Andrew Gibbs, Hlengiwe Shozi, Hope Ngobese, Hilton Humphries, Paul K Drain, Nigel Garrett, Jienchi Dorward, Lindani Msimango, Andrew Gibbs, Hlengiwe Shozi, Hope Ngobese, Hilton Humphries, Paul K Drain, Nigel Garrett, Jienchi Dorward

Abstract

Background: Providing viral load (VL) results to people living with HIV (PLHIV) on antiretroviral therapy (ART) remains a challenge in low and middle-income countries. Point-of-care (POC) VL testing could improve ART monitoring and the quality and efficiency of differentiated models of HIV care. We assessed the acceptability of POC VL testing within a differentiated care model that involved task-shifting from professional nurses to less highly-trained enrolled nurses, and an option of collecting treatment from a community-based ART delivery programme.

Methods: We undertook a qualitative sub-study amongst clients on ART and nurses within the STREAM study, a randomized controlled trial of POC VL testing and task-shifting in Durban, South Africa. Between March and August 2018, we conducted 33 semi-structured interviews with clients, professional and enrolled nurses and 4 focus group discussions with clients. Interviews and focus groups were audio recorded, transcribed, translated and thematically analysed.

Results: Amongst 55 clients on ART (median age 31, 56% women) and 8 nurses (median age 39, 75% women), POC VL testing and task-shifting to enrolled nurses was acceptable. Both clients and providers reported that POC VL testing yielded practical benefits for PLHIV by reducing the number of clinic visits, saving time, travel costs and days off work. Receiving same-day POC VL results encouraged adherence amongst clients, by enabling them to see immediately if they were 'good' or 'bad' adherers and enabled quick referrals to a community-based ART delivery programme for those with viral suppression. However, there was some concern regarding the impact of POC VL testing on clinic flows when implemented in busy public-sector clinics. Regarding task-shifting, nurses felt that, with extra training, enrolled nurses could help decongest healthcare facilities by quickly issuing ART to stable clients. Clients could not easily distinguish enrolled nurses from professional nurses, instead they highlighted the importance of friendliness, respect and good communication between clients and nurses.

Conclusions: POC VL testing combined with task-shifting was acceptable to clients and healthcare providers. Implementation of POC VL testing and task shifting within differentiated care models may help achieve international treatment targets.

Trial registration: NCT03066128 , registered 22/02/2017.

Keywords: Acceptability; Differentiated care; HIV; Point-of-care; Qualitative; Viral load testing.

Conflict of interest statement

The authors have no competing interests to declare.

References

    1. World Health Organisation . Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection. 2015.
    1. Peter T, Ellenberger D, Kim AA, Boeras D, Messele T, Roberts T, et al. Early antiretroviral therapy initiation: access and equity of viral load testing for HIV treatment monitoring. Lancet Infect Dis. 2017;17:e26–e29. doi: 10.1016/S1473-3099(16)30212-2.
    1. El-Sadr WM, Rabkin M, Nkengasong J, Birx DL. Realizing the potential of routine viral load testing in sub-Saharan Africa. J Int AIDS Soc. 2017;20:e25010. doi: 10.1002/jia2.25010.
    1. Dorward J, Garrett N, Quame-Amaglo J, Samsunder N, Ngobese H, Ngomane N, et al. Protocol for a randomised controlled implementation trial of point-of-care viral load testing and task shifting: the simplifying HIV TREAtment and monitoring (STREAM) study. BMJ Open. 2017;7:e017507. doi: 10.1136/bmjopen-2017-017507.
    1. Phillips A, Shroufi A, Vojnov L, Cohn J, Roberts T, Ellman T, et al. Sustainable HIV treatment in Africa through viral-load-informed differentiated care. Nature. 2015;528:S68–S76. doi: 10.1038/nature16046.
    1. Grimsrud A, Bygrave H, Doherty M, Ehrenkranz P, Ellman T, Ferris R, et al. Reimagining HIV service delivery: the role of differentiated care from prevention to suppression: the. J Int AIDS Soc. 2016;19:21484. doi: 10.7448/IAS.19.1.21484.
    1. Duncombe C, Rosenblum S, Hellmann N, Holmes C, Wilkinson L, Biot M, et al. Reframing HIV care: putting people at the Centre of antiretroviral delivery. Trop Med Int Heal. 2015;20:430–447. doi: 10.1111/tmi.12460.
    1. Prust ML, Banda CK, Nyirenda R, Chimbwandira F, Kalua T, Jahn A, et al. Multi-month prescriptions, fast-track refills, and community ART groups: results from a process evaluation in Malawi on using differentiated models of care to achieve national HIV treatment goals. J Int AIDS Soc. 2017;20:21650. doi: 10.7448/IAS.20.5.21650.
    1. Wilkinson L, Harley B, Sharp J, Solomon S, Jacobs S, Cragg C, et al. Expansion of the adherence Club model for stable antiretroviral therapy patients in the cape metro, South Africa 2011-2015. Trop Med Int Heal. 2016;21:743–749. doi: 10.1111/tmi.12699.
    1. Dorward J, Drain PK, Garrett N. Point-of-care viral load testing and differentiated HIV care. Lancet HIV. 2018;5:e8–e9. doi: 10.1016/S2352-3018(17)30211-4.
    1. Drain PK, Dorward J, Violette L, Quame-Amaglo J, Thomas KK, Samsunder N, et al. Point-of-care HIV viral load testing combined with task shifting to improve treatment outcomes (STREAM): findings from an open-label, non-inferiority, randomised controlled trial. Lancet HIV. 2020;7(4):e229–e237. doi: 10.1016/s2352-3018(19)30402-3.
    1. Daneau G, Gous N, Scott L, Potgieter J, Kestens L, Stevens W. Human immunodeficiency virus (HIV)-infected patients accept finger stick blood collection for point-of-care CD4 testing. PLoS One. 2016;11:e0161891. doi: 10.1371/journal.pone.0161891.
    1. Spooner E, Govender K, Reddy T, Ramjee G, Mbadi N, Singh S, et al. Point-of-care HIV testing best practice for early infant diagnosis: an implementation study. BMC Public Health. 2019;19:731. doi: 10.1186/s12889-019-6990-z.
    1. Wynberg E, Cooke G, Shroufi A, Reid SD, Ford N. Impact of point-of-care CD4 testing on linkage to HIV care: a systematic review. J Int AIDS Soc. 2014;17:18809. doi: 10.7448/IAS.17.1.18809.
    1. Jani IV, Meggi B, Loquiha O, Tobaiwa O, Mudenyanga C, Zitha A, et al. Effect of point-of-care early infant diagnosis on antiretroviral therapy initiation and retention of patients. AIDS. 2018;32(11):1453–1463. doi: 10.1097/QAD.0000000000001846.
    1. Mtapuri-Zinyowera S, Chiyaka ET, Mushayi W, Musuka G, Naluyinda-Kitabire F, Mushavi A, et al. PIMA point of care CD4+ cell count Machines in Remote MNCH settings: lessons learned from seven districts in Zimbabwe. Infect Dis Res Treat. 2013;6:51–60.
    1. Pai NP, Wilkinson S, Deli-Houssein R, Vijh R, Vadnais C, Behlim T, et al. Barriers to implementation of rapid and point-of-care tests for human immunodeficiency virus infection: findings from a systematic review (1996-2014) Point Care. 2015;14:81–87.
    1. Engel N, Davids M, Blankvoort N, Pai NP, Dheda K, Pai M. Compounding diagnostic delays: a qualitative study of point-of-care testing in South Africa. Trop Med Int Heal. 2015;20:493–500. doi: 10.1111/tmi.12450.
    1. Shaw JLV. Practical challenges related to point of care testing. Pract Lab Med. 2016;4:22–29. doi: 10.1016/j.plabm.2015.12.002.
    1. Georgeu D, Colvin CJ, Lewin S, Fairall L, Bachmann MO, Uebel K, et al. Implementing nurse-initiated and managed antiretroviral treatment (NIMART) in South Africa: a qualitative process evaluation of the STRETCH trial. Implement Sci. 2012;7:66. doi: 10.1186/1748-5908-7-66.
    1. Okyere E, Mwanri L, Ward P. Is task-shifting a solution to the health workers’ shortage in northern Ghana? PLoS One. 2017;12:1–22. doi: 10.1371/journal.pone.0174631.
    1. Dorward J, Msimango L, Gibbs A, Shozi H, Tonkin-Crine S, Hayward G, et al. Understanding how community antiretroviral delivery influences engagement in HIV care: a qualitative assessment of the centralised chronic medication dispensing and distribution programme in South Africa. BMJ Open. 2020;10(5):e035412. doi: 10.1136/bmjopen-2019-035412.
    1. Stime KJ, Garrett N, Sookrajh Y, Dorward J, Dlamini N, Olowolagba A, et al. Clinic flow for STI, HIV, and TB patients in an urban infectious disease clinic offering point-of-care testing services in Durban. BMC Health Serv Res. 2018;18:363. doi: 10.1186/s12913-018-3154-2.
    1. Dietz CA, Ablah E, Reznik D, Robbins DK. Patients’ attitudes about rapid Oral HIV screening in an urban, free dental clinic. AIDS Patient Care STDs. 2008;22:205–212. doi: 10.1089/apc.2007.0235.
    1. Liu A, Kilmarx PH, Supawitkul S, Chaowanachan T, Yanpainsarn S, Chiakummao S, et al. Rapid whole blood finger stick test for HIV. JAcquir Immune Defic Syndr. 2003;33:194–198. doi: 10.1097/00126334-200306010-00013.
    1. Mashamba-Thompson T, Jama N, Sartorius B, Drain P, Thompson R. Implementation of point-of-care diagnostics in rural primary healthcare clinics in South Africa: perspectives of key stakeholders. Diagnostics. 2017;7:3. doi: 10.3390/diagnostics7010003.
    1. Rasti R, Nanjebe D, Karlström J, Muchunguzi C, Mwanga-Amumpaire J, Gantelius J, et al. Health care workers’ perceptions of point-of-care testing in a low-income country—a qualitative study in southwestern Uganda. PLoS One. 2017;12:e0182005. doi: 10.1371/journal.pone.0182005.
    1. Bernays S, Paparini S, Seeley J, Rhodes T. “Not taking it will just be like a sin”: young people living with HIV and the stigmatization of less-than-perfect adherence to antiretroviral therapy. Med Anthropol Cross Cult Stud Heal Illn. 2017;36:485–499.
    1. Paparini S, Rhodes T. The biopolitics of engagement and the HIV cascade of care: a synthesis of the literature on patient citizenship and antiretroviral therapy. Crit Public Health. 2016;26:501–517. doi: 10.1080/09581596.2016.1140127.
    1. Jain K, Mshweshwe-Pakela NT, Charalambous S, Mabuto T, Hoffmann CJ. Enhancing value and lowering costs of care: a qualitative exploration of a randomized linkage to care intervention in South Africa. AIDS Care. 2019;31:481–488. doi: 10.1080/09540121.2018.1503636.
    1. Kredo T, Adeniyi FB, Bateganya M, Pienaar ED. Task shifting from doctors to non-doctors for initiation and maintenance of antiretroviral therapy. Cochrane Database Syst Rev. 2014:CD007331.
    1. Fairall L, Bachmann MO, Lombard C, Timmerman V, Uebel K, Zwarenstein M, et al. Task shifting of antiretroviral treatment from doctors to primary-care nurses in South Africa (STRETCH): a pragmatic, parallel, cluster-randomised trial. Lancet. 2012;380:889–898. doi: 10.1016/S0140-6736(12)60730-2.
    1. Mammbona AA, Mavhandu-Mudzusi AH. Enrolled nurses’ experiences of caring for patients living with HIV in a south African rural hospital. Int Nurs Rev. 2019;66:139–146. doi: 10.1111/inr.12480.
    1. Zanolini A, Sikombe K, Sikazwe I, Eshun-Wilson I, Somwe P, Bolton Moore C, et al. Understanding preferences for HIV care and treatment in Zambia: evidence from a discrete choice experiment among patients who have been lost to follow-up. PLoS Med. 2018;15:e1002636. doi: 10.1371/journal.pmed.1002636.
    1. Engel N, Davids M, Blankvoort N, Dheda K, Pant Pai N, Pai M. Making HIV testing work at the point of care in South Africa: a qualitative study of diagnostic practices. BMC Health Serv Res. 2017;17:408. doi: 10.1186/s12913-017-2353-6.

Source: PubMed

Sponsors en medewerkers

Medische omstandigheden

Geneesmiddelinterventies

3
Abonneren