A third-line antiretroviral therapy referral process in the Western Cape : estimating qualification and predictors of referral HIV public health
Thesis (MMed)--Stellenbosch University, 2019.
ENGLISH SUMMARY : Introduction: HIV/AIDS is a major contributor to burden of disease in South Africa and with more than 3.7 million people receiving ART in the country, the South African ART programme is the largest in the world. Implementation of a universal test-and-treat policy in recent years is expected to significantly increase the number of South Africans on ART. However, increasing exposure to ART may have additional implications for rates of treatment failure and drug resistance, implying a greater need for second and third-line regimens in the future. South Africa initiated the world’s first public sector third-line access programme in 2013. However, there is a paucity of data quantifying the need for third-line therapy in this setting and the programme itself has not been formally evaluated. Objective: The overall objective of the study was to evaluate the third-line ART referral process in the Western Cape. This was undertaken by identifying patients meeting the criteria for referral to the committee, a comparison with patients who were actually referred in the same time period and identification of factors predicting referral. Method: We utilised a three-step study design in relation to the main objectives of the study. Routinely collected data from provincial health information systems (TIER.net, JAC, CDU and NHLS) were analysed to derive an estimate of patients meeting the criteria for referral to the third-line ART committee in the study period. This output was then matched with a list of patients who were actually referred in the same time period. The matching process allowed for delineation into the groups “Met Criteria and Referred”, “Met Criteria and Not Referred” and “Did Not Meet Criteria and Referred.” Predictors of referral were identified by comparison between the patient groups in which referral criteria were met. In the absence of a validation method, we performed sensitivity analyses to evaluate the impact of varying certain parameters on the findings. Results: In the period 01 October 2014 to 30 September 2016, 947 adult patients met criteria for referral to the third-line ART committee. In the same period, 167 adult patients were actually referred. Comparison between the two groups revealed a poor overlap of only 42 patients. In multivariate analysis, independent predictors of referral included receiving care at a hospital rather than a PHC facility (aOR=2.15, 95% CI 1.1-4.2), a higher number of VLs ≥1000 copies/ml whilst on a PI (aOR=1.2, 95%CI 1.01-1.42) and a greater number of years on a PI (aOR=1.25, 95% CI 1.07-1.46). Patients with a six-month gap in dispensing records were less likely to be referred (aOR=0.37, 95% CI 0.17-0.81). Conclusion: This study adds to a limited body of knowledge regarding third-line ART programmes and provides an estimate for the need for third-line therapy in the South African setting. The method for estimating patients meeting the referral criteria could not be validated and is subject to a number of limitations. Nevertheless, the findings indicate missed opportunities for referral and inappropriate referral of patients. Predictors of referral were not unexpected, however clinician awareness of and compliance with the referral criteria remains unknown and may be contributory. Future work should focus on refining and validating the method as well as assessing clinician awareness of the programme.
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