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A LABORATORY BASED APPROACH TO REDUCE LOSS TO FOLLOW UP OF HIV POSITIVE CLIENTS. A LABORATORY BASED APPROACH TO REDUCE LOSS TO FOLLOW UP OF HIV POSITIVE CLIENTS. XIX INTERNATIONAL AIDS CONFERENCE JULY 22-27, 2012 Author: Nwuba Chioma Onyinye cnwuba@msh.org; chioman4u@yahoo.com
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A LABORATORY BASED APPROACH TO REDUCE LOSS TO FOLLOW UP OF HIV POSITIVE CLIENTS
A LABORATORY BASED APPROACH TO REDUCE LOSS TO FOLLOW UP OF HIV POSITIVE CLIENTS XIX INTERNATIONAL AIDS CONFERENCE JULY 22-27, 2012 Author: Nwuba Chioma Onyinye cnwuba@msh.org; chioman4u@yahoo.com Laboratory Systems Strengthening Specialist, Pro-ACT Project Management Sciences for Health, Nigeria Co Authors: T. Dagunduro; C. Umenyi; B. Peters; O. Abolarin; F. Afolayan Management Sciences for Health, Nigeria; Kwara State Ministry of Health.
Background • Efforts to increase access to life-saving antiretroviral therapy (ART), for people living with HIV/AIDS in resource-limited settings has been a great concern under HIV/AIDS national treatment programs in Nigeria. • The progressive loss of patients at every stage in ART programs especially at the point of uptake of CD4 monitoring poses a threat to the achievement of treatment targets.
CD4 T-cell count estimation remains the primary monitoring tool for assessing the success or failure of antiretroviral therapy (ART) under national treatment programs in developing countries. • Unfortunately, in some of these developing countries, this laboratory investigation is only available once a week on clinic days making it difficult for persons who test positive on non- clinic days to have access to baseline CD4 estimation. • Long waiting time coupled with the burden of travelling long distances to and fro clinics for initial blood draw and receipt of CD4 results has led to attrition in the number of clients who test positive to HIV versus the number who eventually commence ART.
Furthermore, shortage of human resources for health also made it difficult to have enough workers attend to patients promptly. Patients have to wait for the few available doctors who are already overburdened by huge workloads to fill laboratory and pharmacy request forms before accessing laboratory investigations or collecting their antiretroviral drugs.
Objective • This paper aims to describe the outcome of interventions to increase uptake of CD4 monitoring and reduce loss to follow up of HIV positive clients in Northern Nigeria.
Location: Kwara State, Nigeria • Date Created: 27th May, 1967 • Capital: Ilorin • Area: 36,825 km • Population: 2,591,555 (2005) • Population Rank: 31st • Number of Languages: Ebira, Nupe and Yoruba • HIV Prevalence: 2.2%
Method: The MSH Approach • Task shifting to data clerks to fill laboratory request forms for CD4 investigations instead of the few available doctors. • Strengthened escort services from the point of enrolment to the laboratory to ensure that clients access laboratory investigations on the same day.
Method: The MSH Approach (cont.) • Introduced point of care blood sample collection for clinics where the laboratory is far from the general out-patient department and ante-natal unit. • Initiated daily access to CD4 investigations for all clients in order to capture those who test positive to HIV on non-clinic days and ensure that they have access to baseline investigations on the same day.
Method: The MSH Approach • Bridged the gap in human resources for health by task shifting to laboratory technicians on the use of automated CD4 equipments after consistent onsite training and supervision. • Initiated daily CD4 investigations (Monday - Friday) and same day receipt of results to reduce the frequency of clinic visits especially for clients attending clinics from long distances and difficult terrains. Fig 2: Lab technicians undergoing training in the use of automated equipments.
Method: The MSH Approach (cont) • Instituted 24 hours turnaround time for receipt of CD4 test results for all HIV positive clients to ensure rapid initiation of eligible clients on ART. • Harmonized patient appointments for antiretroviral drug pick up and laboratory monitoring on the same day in order to improve adherence to clinic appointments. • Integrated ART laboratory into existing general laboratory ensuring that the same phlebotomy point is used for all clients irrespective of their HIV status.
RESULTS: Uptake of Services At the end of twelve months: • Number of HIV positive clients who accessed baseline CD4 investigations at our HIV care and treatment clinic increased from 53.8% to 93.3%. • In addition, the number of pregnant women placed on antiretroviral therapy increased from 50% before the initiation of our interventions to 83% after the interventions. • Furthermore, the number of patients lost to follow up reduced from 58.7% to 10.7% at the end of twelve months.
RESULTS: Health Systems perspective • Average client waiting time on clinic days reduced from 4 hours to 1 hour 30minutes resulting in more clients being willing to access care and treatment services at our clinics. • Laboratory turnaround time for CD4 result which used to be 7 days has reduced to 24 hours resulting in rapid initiation of eligible patients on antiretroviral therapy.
The Ripple Effect • The successes recorded after strengthening health systems for effective delivery of HIV care and treatment services at our pilot treatment center (Specialist Hospital Offa) prompted us to implement these strategies at two other treatment centers in Kwara state (General Hospital, Omuaran and Children Specialist Hospital, Ilorin).
Sustainability and Ownership In order to ensure sustainability, the following measures were put in place • Each hospital management committee drives the program and makes independent decisions necessary for the delivery of quality services. • On site trainings facilitated by each unit head is held for incoming new staff on HIV rapid testing, filling of laboratory and drug request forms, use of automated equipments for laboratory investigations, ARV drug dispensing, adherence etc. This will ensure that more trained health workers are available to attend to patients.
The idea has a 100% buy in from the state government as we neither employ nor pay the salaries of health workers working in these clinics. The state government does so.
Conclusion • Strengthening of laboratory health systems is vital in addressing the challenges of limited health service that prevents large numbers of HIV positive clients in rural communities from accessing care and treatment services. • Uptake of care and treatment services for positive clients living in hard to reach communities can be improved through task shifting, strengthening health systems to provide daily ART laboratory and pharmacy services, shortened client waiting time and improved system linkages.
Acknowledgements • USAID Nigeria • PEPFAR • Management Sciences for Health, Nigeria • Kwara State Ministry of Health, Nigeria The management and staff of SH Offa, GH Omuaran and CSH Ilorin for supporting the provision of care and treatment services to HIV positive clients in Nigeria.
