On the front line of HIV virological monitoring: barriers and facilitators from a provider perspective in resource-limited settings

Abstract

Scale-up of viral load (VL) monitoring for HIV-infected patients on antiretroviral therapy (ART) is a priority in many resource-limited settings, and ART providers are critical to effective program implementation. We explored provider-perceived barriers and facilitators of VL monitoring. We interviewed all providers (n = 17) engaged in a public health evaluation of dried blood spots for VL monitoring at five ART clinics in Malawi. All ART clinics were housed within district hospitals. We grouped themes at patient, provider, facility, system, and policy levels. Providers emphasized their desire for improved ART monitoring strategies, and frustration in response to restrictive policies for determining which patients were eligible to receive VL monitoring. Although many providers pled for expansion of monitoring to include all persons on ART, regardless of time on ART, the most salient provider-perceived barrier to VL monitoring implementation was the pressure of work associated with monitoring activities. The work burden was exacerbated by inefficient data management systems, highlighting a critical interaction between provider-, facility-, and system-level factors. Lack of integration between laboratory and clinical systems complicated the process for alerting providers when results were available, and these communication gaps were intensified by poor facility connectivity. Centralized second-line ART distribution was also noted as a barrier: providers reported that the time and expenses required for patients to collect second-line ART frequently obstructed referral. However, provider empowerment emerged as an unexpected facilitator of VL monitoring. For many providers, this was the first time they used an objective marker of ART response to guide clinical management. Providers' knowledge of a patient's virological status increased confidence in adherence counseling and clinical decision-making. Results from our study provide unique insight into provider perceptions of VL monitoring and indicate the importance of policies responsive to individual and environmental challenges of VL monitoring program implementation. Findings may inform scale-up by helping policy-makers identify strategies to improve feasibility and sustainability of VL monitoring.

Keywords: HIV; provider perceptions; resource-limited settings; viral load monitoring.

Figures

Figure 1. WHO VL Monitoring Scale-up(WHO, 2014)

Phased implementation of viral load monitoring as described in the World Health Organization's Technical and Operational Considerations for Implementing HIV Viral Load Testing identifies human resources, including training ART providers, in Phase II of the scale-up activities.

Figure 2. Dried blood spot (DBS) study flow

ART patients receiving care at enrolling clinics were briefed as to study purpose and eligibility during the morning education section. After identifying eligible patients, providers completed informed consent forms and study-specific case report forms for patient demographics, clinical history, and adherence. DBS specimens were collected and, after appropriate drying time, transported to the central laboratory in Lilongwe where specimens were tested. Results were returned to clinics using email, SMS and/or in-person hard-copy printouts. Patients were supposed to receive the results at their next visit. Each site was encouraged to designate tasks and responsibilities to clinic personnel in a manner that suited existing clinic flow, patient volume, and staffing constraints. The provider interviews, the topic of this paper, occurred once the study procedures had begun at a given clinic.

Figure 3. Multilevel framework

This figure outlines the multilevel factors that relate to provider acceptability, perceived barriers and facilitators of viral load (VL) monitoring using DBS. The framework identified patient, provider, facility, system and policy factors that are examined in our assessment of barriers to and facilitators of incorporating VL monitoring into clinical practice. ART, antiretroviral therapy; B, barrier; DBS, dried blood spot; F, facilitator