WHAT WAS THE PROBLEM?
The rapid scale-up of antiretroviral therapy (ART) and viral load (VL) monitoring in Kenya has led to increasing numbers of people living with HIV (PLHIV) receiving both life-saving treatment and improved knowledge of viral suppression. This, in turn, contributes to Kenya achieving The Joint United Nations Programme on HIV and AIDS (UNAIDS) global epidemic control goal of 73% of all PLHIV being virally suppressed. One barrier to realizing this goal, is poor or limited responses when responding to PLHIV with viremia. Viremia is generally defined as the presence of viruses in the bloodstream. An HIV-positive person is considered to have viremia when they have greater than or equal to 1,000 copies of HIV per 1 milliliter of blood in their body (≥ 1,000 copies/mL). Challenges in providing rapid and comprehensive care to patients with high VL has led to poor optimization of ART adherence, delayed repeat VL testing, and delayed switch to 2nd-line ART.
What is the solution?
The establishment of viremia clinics was an initiative to address the gaps and challenges in the monitoring and management of patients with high VL, and function as a form of differentiated care for unstable clients with high VL. Held at least one day a month, the viremia clinic utilizes a multidisciplinary team (MDT) model and focuses on enhanced case-management and a patient-centered approach. This model is aimed at identifying patient-specific adherence barriers and tailoring interventions to address the patients’ specific needs. Patients are empowered to make joint decisions with their providers to improve their ART adherence.
What was the impact?
All 24 HIV clinics in Nairobi County, with approximately 22,000 HIV-infected clients on ART, have adopted the viremia clinic model. Sixteen stand-alone prevention of mother-to-child transmission (PMTCT) sites are also involved. These are small maternal and child health (MCH) facilities providing ART for pregnant and breastfeeding women only. Since the inception of the model, an improvement in VL testing of eligible patients and VL suppression rates have been observed.
Preliminary data show an improvement in the proportion of PLHIV who received enhanced adherence counseling (EAC) sessions, repeat VL testing, and initiate second-line ART (in individuals with persistent viremia despite optimized adherence (Figure 1)). Ongoing implementation of the viremia clinic model with goals of improved EAC and monitoring of the program will hopefully show subsequent improvements in re-suppression rates in individuals with initial high VL.
how does it work?
The clinic date is established after identifying a day (usually a fixed day every month) when the clinic has a lower patient volume. Patients with viremia are typically booked in the morning and follow a structured patient flow. Clinics begin with group education on common factors that contribute to viremia, and possible solutions to address these factors. Patients also receive one-on-one counseling using the nationally developed adherence tools (see below). During these sessions, patients work jointly with the adherence counselors to identify barriers and potential solutions to adherence.
In between clinic visits, peer educators provide multiple support functions, such as serving as case managers, conducting home visits to enhance support, identifying other factors that could contribute to ART non-adherence, and managing missed appointments. All patients receive one home visit after their first viremia clinic visit. Additional visits may be made for those requiring more support.
systems & services level
The structure and operationalization of the viremia clinics encompasses key aspects for service delivery. These include clinic reorganization, case management, and a robust system for patient follow-up (Figure 2).
The viremia clinic model is easy to introduce to all existing HIV clinics, and requires no significant extra resources. While the model described includes an MDT of various background providers, clinics with fewer providers have still benefited from the model by establishing a dedicated clinic day for patients with viremia, and following the general organizational structure and patient flow as outlined. Low-volume clinics can choose to incorporate the model within their current clinic structure.
In Nairobi County, where multiple partners support ART sites, the strategy has received immense support from the county following repeated dissemination of this strategy in best practice/quality improvement meetings. The county’s recommendation for broad scale-up of this model to all facilities has led to more facilities establishing viremia clinics.
management & oversight
Monitoring: UMB developed a Viremia Register (attached), which collects regular data for high VL clients. This information allows for the monitoring of compliance with, and timeliness of, interventions. The clinician is responsible for reviewing the Viremia Register at the beginning and end of each clinic. This allows the clinician to monitor the provision of services, and initiate corrective actions when necessary.
Through performance review and quality management approaches, viremia clinics have increased the efficiency and quality of the MDT approach to high VL patient case management. During visits to the facilities, UMB teams review the Viremia Registers for service delivery quality assurance and quality improvement. Indicators reviewed include time between EAC sessions, time to repeat VL, and time to switch to 2nd or 3rd-line ART. After ART regimen switch, patients continue to receive individualized adherence support during their clinic visits and have repeat VL testing 6 months after the medication switch. Patients with VL suppression are subsequently transitioned back to attend regular clinics.