Early Warning Indicators for HIV Drug Resistance in Cameroon during the Year 2010

BACKGROUND: Rapid scale-up of antiretroviral therapy (ART) in resource-limited settings is accompanied with an increasing risk of HIV drug resistance (HIVDR), which in turn could compromise the performance of national ART rollout programme. In order to sustain the effectiveness of ART in a resource-limited country like Cameroon, HIVDR early warning indicators (EWI) may provide relevant corrective measures to support the control and therapeutic management of AIDS. METHODS: A retrospective study was conducted in 2010 among 40 ART sites (12 Approved Treatment Centers and 28 Management Units) distributed over the 10 regions of Cameroon. Five standardized EWIs were selected for the evaluation using data from January through December, among which: (1) Good ARV prescribing practices: target = 100%; (2) Patient lost to follow-up: target ≤ 20%; (3) Patient retention on first line ART: target ≥ 70%; (4) On-time drug pick-up: target ≥ 90%; (5) ARV drug supply continuity: target = 100%. Analysis was performed using a Data Quality Assessment tool, following WHO protocol. RESULTS: THE NUMBER OF SITES ATTAINING THE REQUIRED PERFORMANCE ARE: 90% (36/40) for EWI(1), 20% (8/40) for EWI(2); 20% (8/40) for EWI(3); 0% (0/37) for EWI(4); and 45% (17/38) for EWI 5. ARV prescribing practices were in conformity with the national guidelines in almost all the sites, whereas patient adherence to ART (EWI(2), EWI(3), and EWI(4)) was very low. A high rate of patients was lost-to-follow-up and others failing first line ART before 12 months of initiation. Discontinuity in drug supply observed in about half of the sites may negatively impact ARV prescription and patient adherence. These poor ART performances may also be due to low number of trained staff and community disengagement. CONCLUSIONS: The poor performance of the national ART programme, due to patient non-adherence and drug stock outs, requires corrective measures to limit risks of HIVDR emergence in Cameroon

Facilitating person‐centred care: integrating an electronic client feedback tool into continuous quality improvement processes to deliver client‐responsive HIV services in the Democratic Republic of Congo

Abstract Introduction Engaging communities in the design, implementation and monitoring of health services is critical for delivering high‐quality, person‐centred services that keep people living with HIV engaged in care. The USAID‐funded Integrated HIV/AIDS Project in Haut‐Katanga (IHAP‐HK) integrated an electronic client feedback tool into continuous quality improvement (CQI) processes. We aimed to demonstrate this system's impact on identifying and improving critical quality‐of‐care gaps. Methods Through stakeholder and empathy mapping, IHAP‐HK co‐designed a service quality monitoring system—comprising anonymous exit interviews and ongoing monitoring through CQI cycles—with people living with HIV, facility‐based providers and other community stakeholders. IHAP‐HK trained 30 peer educators to administer oral, 10‐ to 15‐minute exit interviews with people living with HIV following clinic appointments, and record responses via the KoboToolbox application. IHAP‐HK shared client feedback with facility CQI teams and peer educators; identified quality‐of‐care gaps; discussed remediation steps for inclusion in facility‐level improvement plans; and monitored implementation of identified actions. IHAP‐HK tested this system at eight high‐volume facilities in Haut‐Katanga province from May 2021 through September 2022. Results Findings from 4917 interviews highlighted wait time, stigma, service confidentiality and viral load (VL) turnaround time as key issues. Solutions implemented included: (1) using peer educators to conduct preparatory tasks (pre‐packaging and distributing refills; pulling client files) or escort clients to consultation rooms; (2) limiting personnel in consultation rooms during client appointments; (3) improving facility access cards; and (4) informing clients of VL results via telephone or home visits. Due to these actions, between initial (May 2021) and final interviews (September 2022), client satisfaction with wait times improved (76% to 100% reporting excellent or acceptable wait times); reported cases of stigma decreased (5% to 0%); service confidentiality improved (71% to 99%); and VL turnaround time decreased (45% to 2% informed of VL results 3 months after sample collection). Conclusions Our results showed the feasibility and effectiveness of using an electronic client feedback tool embedded in CQI processes to collect client perspectives to improve service quality and advance client‐responsive care in the Democratic Republic of Congo. IHAP‐HK recommends further testing and expansion of this system to advance person‐centred health services

Overall national ART performance for each EWI.

<p>Overall national ART performance for each EWI.</p

Evaluation of EWIs in each of the 40 surveyed sites during the year 2010.

<p>In <i>“</i><b><i>Bold</i></b><i>”</i>: EWI reaching the required target. NV: Not Validated. NA: Not Available.</p><p><u>EWI</u>: Early Warning Indicator.</p><p><u>EWI₁</u>: Percentage of patients initiated on an appropriate first line ARV drug regimen, following national guidelines (Required target performance: 100%);</p><p><u>EWI₂</u>: Percentage of patient lost to follow-up after 12 months of enrolment to ART (Required target performance: ≤20%);</p><p><u>EWI₃</u>: Percentage of patient retained on appropriate first line ART after 12 month of treatment (Required target performance: ≥70%);</p><p><u>EWI₄</u>: Percentage of patients picking-up their ARV drugs on-time at the pharmacy of the ART site (Required target performance: ≥90%);</p><p><u>EWI₅</u>: Percentage of months without ARV drug shutdown at the pharmacy of the ART site (Required target performance: 100%).</p

Socio-demographic and medical data of the study population.

<p><b>Legend </b><a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0072680#pone-0072680-t001" target="_blank"><b>table 1:</b></a> ART: Antiretroviral therapy; HAART: Highly Active Antiretroviral therapy;</p><p>PMTCT: prevention of mother-to-child transmission; IQR: Interquartile range.</p

HIV drug resistance at enrollment on ART.

<p><b>Legend </b><a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0072680#pone-0072680-t002" target="_blank"><b>table 2</b>:</a> PI: protease inhibitor; NRTI: nucleoside reverse transcriptase inhibitor; NNRTI: non-nucleoside reverse transcriptase inhibitor; HAART: highly active antiretroviral therapy; VL: viral load; LTFU: lost to follow-up; NVP: nevirapine; 3TC: lamivudine; AZT: zidovudine; d4T: stavudine; EFV: efavirenz.</p

Drug resistance-associated mutations at 12 months of ART.

<p><b>Legend </b><a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0072680#pone-0072680-t004" target="_blank"><b>table 4</b>:</a> PI: protease inhibitor; NRTI: nucleoside reverse transcriptase inhibitor; NNRTI: non-nucleoside reverse transcriptase inhibitor; HIVDR: HIV Drug Resistance.</p

Staff/Patient ratio in the overall study population.

<p>Staff/Patient ratio in the overall study population.</p

Virologic outcome at the study endpoint (M12).

<p><u>Legend</u>: NA: not applicable.</p