Provider-perceived barriers and facilitators to viral load monitoring for HIV-positive individuals in resource-limited settings

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

Rutstein SE, Golin CE, Wheeler SB, Kamwendo D, Hosseinipour MC, Weinberger M, Miller WC, Biddle AK, Soko A, Mkandawire M, Mwenda R, Sarr A, Gupta S, Mataya R. AIDS Care. 2015 Aug 17:1-10. [Epub ahead of print]

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 counselling 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.

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Editor’s notes: Viral load monitoring for HIV-positive individuals is gaining prominence as a method for monitoring responses to antiretroviral therapy (ART) and for identifying treatment failure. It is considered more accurate (in terms of its sensitivity and specificity) than alternative methods (e.g., CD4 cell counts). ART providers are critical to the implementation of viral load scale-up as it tends to be resource heavy and providers are tasked with numerous responsibilities in order to achieve individual and public health benefits. Using data from in-person interviews with providers on the frontline of ART management in five ART clinics in Malawi, this study explored multi-level barriers to, and facilitators for incorporating viral load monitoring into daily clinical practice. Study results illustrated a complex set of interconnected provider–identified barriers and facilitators that occurred at multiple levels. In terms of facilitators, high patient demand for viral load testing reinforced provider-perceived benefits of viral load monitoring. In addition, placing an emphasis on provider empowerment during viral load scale-up activities was thought to increase providers’ willingness to adopt additional responsibilities. Barriers identified by providers included the additional burden associated with viral load monitoring such as the time required in completing adherence assessment forms. Related to this was a barrier identified at the facility level by providers around shortage of staff. This was in particular identified as an impediment to completing viral load monitoring activities. Furthermore, inconsistent staffing alongside reluctance of rotating staff to participate in viral load monitoring activities were cited as contributors to people’s failure to return to scheduled clinic visits. Barriers at the system level were around time and expenses required for people to collect second-line ART which then obstructed referrals to viral load monitoring. Further, providers expressed frustration over a policy in Malawi that dictates only certain time points from ART exposure in order to be eligible for viral load monitoring. Hence, they felt forced to ration a service that was considered useful for guiding clinical practice and counselling people.

In order to address some of these barriers, the authors suggest that issues around workload burden and shortage of trained staff at facilities be addressed by expanding provider-to-patient ratios at ART clinics, broadening the scope of practice and training a lower cadre of health workers to facilitate programme sustainability. Furthermore, to synchronise facility, system and policy level interfaces, shortcomings in data management systems needed to be overcome. To that end, improving coverage of mobile networks and internet connectivity to outlying clinics would help facilitate reliable clinic-laboratory communication. Also, decentralised distribution of second-line ART drugs along with improved supply chain procedures should be considered to minimise stock-outs for individuals seeking viral load monitoring in more remote areas. Further, in order to address the issue around Malawi’s strict eligibility criteria, policy-makers need to make an effort to design provider trainings and patient education materials with clarity around the criteria in order to optimise access to limited viral load monitoring opportunities for people at highest risk of ART failure. Another option to improve access is ‘catch up’ testing where every individual on ART for more than two years receives a single test and then returns to biannual eligibility. Even though the results from this study are exploratory, they do provide useful insights into the perceived barriers and facilitators faced by providers around viral load monitoring. Overall, viral load monitoring can be used as a tool to help providers improve the quality of HIV care they deliver, if certain barriers are overcome.

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