By: Felicity Basson (SA SURE Operations Manager) and Judith King (SA SURE Project Copy and Content Editor)
Guidance from UNAIDS confirms that routine viral load tests are the most accurate way of determining whether antiretroviral therapy (ART) is working to suppress replication of HIV. Achieving viral suppression protects the body's immune system, helps people living with HIV stay healthy, prevents transmission of HIV to other people, and can reduce the need for more expensive second- and third-line ART regimens.
A viral load test measures the number of HIV particles per millilitre of blood. In a person on treatment, a low viral load indicates that the virus is less active in the body. A high viral load indicates either that the medication is not being taken properly, or that the virus is becoming resistant to the medication.
Healthcare workers play a crucial role in ensuring consistent viral load monitoring for HIV-positive children on ART, guiding the process of disclosure to the child, explaining the complexities of administering paediatric formulations to caregivers, and providing ongoing support for treatment adherence.
Progress at Amazizi Clinic
In uThukela District, there are 5 101 patients on ART in the 0−19 age group, and the overall district rate for viral load suppression among this group is 73%.
Amazizi Clinic in Bergville serves 111 of these patients, and has achieved a viral load suppression rate of 83%.
Amazizi Clinic in Bergville
The Health Systems Trust's SA SURE Project team has strengthened the capacity of the facility's staff to improve viral load management for HIV-positive children on ART. Sister Hloniphile Sive, a Nurse Clinician working at the clinic, describes how this has been accomplished.
Sister Hloniphile Sive, Nurse Clinician at Amazizi Clinic
"At Amazizi Clinic, we implement the case management approach, providing the mothers and their children on ART with enhanced adherence counselling and, if necessary, an adjusted treatment plan," says Sister Sive. "As part of our quality improvement (QI) planning, we have formed a support group for the mothers, and we schedule household visits to those who can't attend the clinic during the week. To accommodate the individual circumstances of caregivers needing these services, our staff also work flexi-hours (sometimes until 7pm in the evening), and on three of every four weekends in a month."
In November 2021, the clinic identified a backlog of 40 children who were due for viral load testing. Through implementing the QI service interventions, the team traced and tested 32 of these children by the end of January 2022. Tracing efforts were heightened to find the eight children who were still due for testing, and by the end of February, all of them had been found.
While four of these remaining eight children then received their viral load tests, the remaining four were found to be victims of abuse, and were referred to a Social Worker for specialised psychosocial, nutritional and material support, and to protective services to facilitate and supervise their access to viral load management.
Sister Sive notes: "It's important that we share these good practices for supporting children's ART adherence to improve their clinical outcomes and to speed up epidemic control."
Breaking down health system barriers
The revised National Adherence Guidelines include a new set of standard operating procedures − SOP 9: Re-engagement in care − to reduce or remove health system barriers that inhibit continuity of care. These measures require staff to be kind and welcoming, and to recognise the range of challenges that patients face in life-long treatment adherence.
Through close and regular personal contact and a family-centred approach, effective case management focuses on understanding the obstacles that prevent patients from attending the clinic and may result in treatment interruption or total disengagement from care.
"In doing everything possible to help patients keep their clinical appointments, caregivers' contexts must be taken into account," advises Sister Sive. "Mothers have their own health concerns, along with financial worries as well as social, emotional and learning needs, so Case Managers must be responsive by facilitating a process that empowers them to identify solutions for anything that can compromise their children's health and wellbeing."
Cultivating treatment literacy
Among the recommendations published in the 2021 Ritshidze 'State of Health' report for KwaZulu-Natal is ensuring treatment literacy for people living with HIV through consultations, counselling, outreach, and health talks at clinics.
During the period from August to September 2021, the Ritshidze survey explored patients' awareness that an undetectable viral load means the treatment is working well. Amazizi Clinic was found to be among the worst-performing facilities in this regard; 17 of the 24 patients surveyed responded that they understood the importance of viral load in relation to their health.
People Living with HIV (PLHIV), and its quarterly reports profile the priorities for improving HIV, TB and other health services in the province's communities. 'Ritshidze' is the tshiVenda term for 'saving our lives'.
Photo credit: Ritshidze
"To improve our patient's treatment literacy," says Sister Sive, "we are strengthening our efforts to educate mothers and caregivers on the benefits of viral load suppression and how it is achieved. During the consultation, we explain each viral load test result, and help to address any problems that the child may have with taking the medication properly and remaining on treatment. Using the diary card, we go through the details of the patient's drug schedule, and record who gives the medication to the child, the names and doses of what is given, where the medication is kept, and when it is given. We also discuss any signs of side-effects [of] or adverse reactions to the medication."
Patient-centred, data-driven services
Combined with prompt, in-depth counselling and long-term follow-up to ensure successful adherence to treatment, the SA SURE Project adopts a data-driven approach for close monitoring of children's treatment outcomes.
This entails accessing and optimising the use of clinic−laboratory interfaced resources, within an effective system that enables periodic tracking of how targeted care interventions for individual children are supporting their treatment journey.
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