Point of care testing

Effect of point-of-care CD4 cell count tests on retention of patients and rates of antiretroviral therapy initiation in primary health clinics: an observational cohort study

Jani IV, Sitoe NE, Alfai ER, Chongo PL, Quevedo JI, Rocha BM, Lehe JD, Peter TF, Lancet. 2011 Oct 29;378(9802):1572-9. Epub 2011 Sep 25

Loss to follow-up of HIV-positive patients before initiation of antiretroviral therapy can exceed 50% in low-income settings and is a challenge to the scale-up of treatment. Jani and colleagues implemented point-of-care counting of CD4 cells in Mozambique and assessed the effect on loss to follow-up before immunological staging and treatment initiation. In this observational cohort study, data for enrolment into HIV management and initiation of antiretroviral therapy were extracted retrospectively from patients' records at four primary health clinics providing HIV treatment and point-of-care CD4 services. Loss to follow-up and the duration of each preparatory step before treatment initiation were measured and compared with baseline data from before the introduction of point-of-care CD4 testing. After the introduction of point-of-care CD4 the proportion of patients lost to follow-up before completion of CD4 staging dropped from 57% (278 of 492) to 21% (92 of 437) (adjusted odds ratio [OR] 0·2, 95% CI 0·15-0·27). Total loss to follow-up before initiation of antiretroviral treatment fell from 64% (314 of 492) to 33% (142 of 437) (OR 0·27, 95% CI 0·21-0·36) and the proportion of enrolled patients initiating antiretroviral therapy increased from 12% (57 of 492) to 22% (94 of 437) (OR 2·05, 95% CI 1·42-2·96). The median time from enrolment to antiretroviral therapy initiation reduced from 48 days to 20 days (p<0·0001), primarily because of a reduction in the median time taken to complete CD4 staging, which decreased from 32 days to 3 days (p<0·0001). Loss to follow-up between staging and antiretroviral therapy initiation did not change significantly (OR 0·84, 95% CI 0·49-1·45). Point-of-care CD4 testing enabled clinics to stage patients rapidly on-site after enrolment, which reduced opportunities for pretreatment loss to follow-up. As a result, more patients were identified as eligible for and initiated antiretroviral treatment. Point-of-care testing might therefore be an effective intervention to reduce pretreatment loss to follow-up.

For abstract access click here [2]

Editor’s note: The rate of loss to follow-up after antiretroviral therapy initiation in resource-constrained settings can be high in the first year but it is nowhere near as high as the loss to follow-up after HIV diagnosis and before treatment initiation. Weak referral links, distances to be travelled to clinics, and high mortality are important reasons. This is the first study to assess whether a diagnostic test could reduce pre-treatment losses to follow-up and the results are resounding. Point-of-care CD4 count using a fingerpick sample replaced a system in which blood samples were sent once a week for testing (median 10 days), patients returned for a staging visit once the results became available (median 17.5 days), and each part of this process took place at a different site (HIV testing, CD4 count blood draw, and staging consultation). 30% of patients had their CD4 test done on the same day they learned they had HIV infection and by 5 days, 90% had received point-of-care CD4 testing. 50% of patients were able to have their staging consultation on the day they completed CD4 count testing. About 21% of patients learned their HIV result, completed their point-of-care CD4 count testing, and had their staging consultation all on the same day. The median time from enrolment to clinical staging for treatment decisions in this study dropped ten-fold from 32 days to 3 days. This is an important contribution to efforts worldwide to increase the efficiency and sustainability of antiretroviral therapy programmes. Improving clinic workflow, developing flexible staffing models to accommodate spikes in patients testing HIV-positive, and other innovations can increase the impact of point-of-care diagnostics on reducing loss-to-follow up, increasing treatment initiation, and ultimately improving patient survival.

HIV testing [4]
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