Introduction of SOP’s and Tools for the VL Monitoring and Drug

Resistance Project

Dr Rochelle AdamsAnnual Workshop on Advanced Clinical Care

Elangeni Hotel

30 August 2019

Our new ART Guidelines are Coming

Virologic Management of Patients

So

urc

e: 2

01

9 A

RT

Clin

ica

l Gu

idelin

es

Do a thorough assessment of the cause of an elevated

VL. Consider the possibility of:

A. Adherence problems

B. Bugs (Intercurrent infections)

C. In-Correct ART dosage

D. Drug Interactions

E. REsistance

Routine VL monitoring at 6 months on ART, 12 months on ART, and 12-monthly thereafter

VL > 1000 c/mL

VL > 1000 c/mL

NNRTI-based regimen

(EFV/NVP)

Consider switching to 2ND Lnine if

virological failure confirmed, i.e.

VL > 1000 c/mL on two consecutive

occasions and adherence issues

addressed

InSTI (DTG) or PI-based regimen*

Consider switching to second-line if virological failure

confirmed, i.e. VL > 1000 c/mL on at least three

occasions over the course of two years, or VL >

1000 c/mL with immunological or clinical failure

(i.e. declining CD4 and/or opportunistic infections)

Repeat VL after 3 months

!VL 50-999 c/mLVL < 50 c/mL

Routine VL

monitoring

SOP’s and Tools

• Developed from best practices seen in

eThekwini to:

Provide framework and step by step process for

operationalising the VL Algorithm

Speak to the 2019 guidelines

Be implemented at any level of facility running ART

programs

Be applicable for the management of paediatric and

nonpregnant adolescent and adult patients on ART

Algorithms, Registers, SOP’s, Tools for VL Monitoring and Management

Algorithm

Algorithm for managing

patients with their first VL ≥

50 c/ml

Algorithm for managing non-

pregnant patients on a DTG/PI based regimen for 12

months with two VL ≥ 1000 c/ml

Register

Baseline Chart audit tool

VL Sample log

First High VL register

High VL register for Patients on DTG Or

Protease Inhibitor Based Regimens > 12 Months

With 2 VL ≥1000

Adherence Tools

EAC sessions for paediatric

patients

EAC sessions for adolescent

patients

EAC sessions for adult patients

Baseline EAC Plan

Quality Assurance Tools for

Ongoing Audits

Adult chart review Tool

Paediatric chart review Tool

Roles and Responsibilities of QA team members

VL Champion activities

Standard Operating Procedure for First Line Viral Load Management

Standard Operating Procedure for the Management of high viral load in non-pregnant adolescents

and adults on an INSTI- based or Protease Inhibitor (PI) - based antiretroviral therapy

Algorithms

We have updated the

Algorithms which now speak

to paediatrics and adults

Registers

Enhanced Adherence Counselling Worksheets

Adolescent

Paediatric

Paediatric, Adolescent, Adult Tools

Adult

Quality assurance tools

•It’s a simple statement at the top of the algorithm

•Applicable to all non pregnant ART patients

•But in your facility

•Who makes sure it gets done?

•What do we do to make sure its done?

•When do we do it?

•How do we do it?

Routine VL monitoring at 6 months on ART, 12 months on

ART, and 12-monthly thereafter

Addressing Roles and Responsibilities

The SOP that holds MOST of it together

• Part A:

• Outlines essential

procedures required

to ensure a

successful VL

monitoring

• Part B:

• Management of the

first episode of a VL≥

50 c/mL

• Used in conjunction

with

• Adherence tools

• Algorithm 1

• Register 3

Making VL Monitoring Routine Tools

Register 1: Baseline Chart

audit tool:

• Once off process to verify

clinic ART registry

• Identify active patients and

patient VL status

Register 2: VL sample log

• Catalogues all VL done

• For tracing results (barcode)

• For identifying

unsuppressed VL

Standard Operating Procedure for Managing Non- Pregnant ART Patients With First Viral Load ≥ 50 copies/ml

Algorithm 1

• Outlays routine tasks from

SOP on the right for

making VL Monitoring

routine

• Visit by visit process and

management after 1st

unsuppressed VL

• Use with Register 3 which

tracks patient mx and

outcomes

• Supported by adherence

tools

What to do if 2 VL ≥ 1000 c/mL on DTG or PI?

So our guideline

says this

So we

developed

this

Standard Operating Procedure for Managing Non-Pregnant Patients on a DTG/PI based Regimen for 12 Months & 2 Viral Loads ≥ 1000 copies/ml

Algorithm 2

• Outlays routine tasks from

SOP on the right for

making VL Monitoring

routine

• Visit by visit process and

management after 1st

unsuppressed VL

• Use with Register 4 which

tracks patient

management and

outcomes

Other evidence that they work anywhere!

•Facility in Eastern Cape

•Current TROA +- 1700

•SOP’s and Tools presented 27 March 2019

•Project implemented 01 April 2019

• .

Jan 2019 Feb 2019 March 2019

VL Due 17 22 20

VL done 5 6 3

VL coverage 29.4% 27.3% 15%

VL suppressed 5 6 3

Activities

• Utilizing Base line V/L audit chart, V/L register, FLART register, SLART register.

• VL champion takes 2 hours out of her 8 hours per day dedicated to the project

• Retrieval of VL due patients day before by data capturer

• Reminders attached: Sticker/Lab form

• Files distributed to all consulting rooms in the morning

• Queue marshal directs patients to correct rooms as they

arrive

• Data capturer collects files for VL Champion at the end of

the day

• Chart audits of 118 patients with unsuppressed VL

Results

•Aim:• To improve viral load completion rate from 14% to 90% starting from the 01 April 2019 to the 31 May 2019.

March 19 April 19 May 19 June 2019

VL Due

20 92 150 89

VL done

3 231 283 138

VL coverage

15%

First of last 2 slides!

How do we assess how our patients are being managed and

intervene with targeted interventions?

Quality Assurance Tools for Ongoing Audits

Paediatric & Adult Tools

• 2 Pager

• Reviews initiation visit

• TB screening cascade

• VL monitoring and

management

• Switch from NNRTI to

DTG

• Basic Mx of abnormal

results

• Completion of other

routine care

Acknowledgements

The CQUIN Learning Network

25

• Dr Henry Sunpath- Project Co-Ordinator

• CAPRISA ACC Staff

• eThekwini District Management and DOH

Facility staff

• UKZN Department of Infectious Disease

• Maternal and Adolescent Child Health

• REVAMP team

• Epicentre

This project was supported by the Grant or Cooperative Agreement Number U2GGH001142, funded by the Centers for Disease Control and Prevention. Itscontents are solely the responsibility of the presenters and do not necessarilyrepresent the official views of the U.S. Centers for Disease Control and

Prevention or the U.S. Department of Health and Human Services