Multi-pronged Launch of Viral Load Monitoring in Haiti Will Lead to Better Outcomes
Viral load monitoring is the last step in the continuum of care to ensure HIV epidemic control and to validate efforts to improve testing, access to treatment, adherence and retention. Over the course of FY16, I-TECH provided technical assistance to the Ministry of Public Health and Population (known by its French acronym, MSPP) and its National AIDS Control Program (PNLS) to implement strategies to introduce viral load monitoring into routine patient care. There were three main activities implemented: healthcare worker training, enhanced health information systems and on-site technical assistance.
Training and resources for healthcare providers and laboratories
With funding from CDC/PEPFAR, the National Public Health Lab (LNSP) and the lab at The Haitian Group for the Study of Kaposi’s Sarcoma and Opportunistic Infections (GHESKIO) received materials and training to be able to conduct viral load testing. LNSP also put in place transportation system for DBS samples to be sent from sites to the labs for testing. However, upstream, healthcare workers and laboratory technicians need to understand when to order a viral load test for a patient and how to draw samples to send to the labs for testing. In collaboration with PNLS and CDC, I-TECH provided a 10-module training to 120 HCW and 60 laboratory technicians from all 10 geographic regions in Haiti over the course of 4 trainings from February to August 2016 to present the clinical protocol for viral load testing and how to interpret results. Towards the end of the year, I-TECH worked with PNLS to revise the MSPP HIV/AIDS Treatment Guidelines to include critical information on viral load testing and monitoring for patients as well as the test and treat strategy. These guidelines are due for completion by the end of October 2016.
Enhancement of National EMR to Include Viral Load Alerts
iSanté, the national electronic medical record, is deployed in 115 sites throughout Haiti and used by providers both at point-of-care during a patient consultation and for retrospective data entry and analysis. In the 17.1 version of the software, I-TECH added viral load alerts and reports. This new functionality allows providers to see if a patient is eligible for a viral load test according to the guidelines and prompts the provider to order a test if the patient has not received one according to the recommended schedule. This type of clinical decision support helps HCW implement viral load testing systematically and monitor performance on the indicator.
Reinforcing site-level implementation through clinical mentoring
Following the didactic training provided, I-TECH Clinical Mentors conducted technical assistance visits in 8 high HIV patient volume sites where viral load testing and monitoring implementation has begun. The key focus during the visit is to review protocols with HCW to ensure all eligible patients receive a viral load test according to guidelines. I-TECH clinical mentors also reinforce the use of iSanté to enter and analyze results. The EMR serves as a critical tool in the clinical decisions that are made to improve patient outcomes. Mentors review results with clinicians to assess the next steps: of those patients who are not virally suppressed, some have excellent ART adherence. For this group, the provider may consider drug resistance and request to change regimens. For patients who have less than optimal adherence, the clinician works with the care team including a social work or psychologist to help the patient improve adherence. For patients who are lost to follow-up (LTFU), the sites work with community health workers to re-establish patients in care and treatment. The mentors also work with lab technicians to review sampling procedures and to ensure collected DBS samples are properly handled and transported to the national or regional labs.
These efforts of training healthcare workers, reinforcing that training on-site, and providing the tools to make good clinical decisions, are beginning to impact epidemic control efforts. Over the course of the next year, I-TECH will continue to reinforce implementation of viral load testing and monitoring so that Haiti may achieve the goal of 80% of PLHIV on treatment with an undetectable level of virus by the end of FY17 and 90% by 2020.