NaHSAR: The 12th National HIV Semi-Annual Review took place this weekend, here in Hhohho.
I must be going deaf. I misheard and thought I was bound for Houston when the clinic supervisor told me I was going to NaHSAR. It should have been held last weekend but there was no room at the Pigg’s Peak Hotel for all the delegates. The organisers tried to change the location to Ezulwini at short notice, but failed. So the three day meeting was deferred to this weekend, clashing with the Southern Africa Region HIV Review meeting. Timetabling is always a problem in Swaziland.
Prior to the meeting we had to write a poster explaining how we had tried to solve a problem related to HIV. Two reviews ago, MSF had done a great piece of work on the effect of “stepped up counselling” (monthly, individual sessions to improve the consistency of taking anti-HIV drugs). We found that about 60% of patients on Anti-Retroviral Therapy (ART) whose treatment was not working (they still had detectable virus in their blood) responded to three sessions of intensive counselling; their improved compliance resulted in ridding the virus from their blood. However, this still left 40% of patients failing their treatment, either because they were still not taking their medication properly or the virus had mutated to a resistant strain.
We couldn’t come up with such a useful piece of research to report. After a brainstorming session, I suggested the idea of measuring our progress to the UNAIDS target of 90-90-90. This means 90% of people know their HIV status, 90% of those who are HIV positive are on appropriate treatment and 90% of those on treatment have undetectable viral loads. If this is achieved by 2020 worldwide, then the HIV epidemic will be under control by 2030. The mathematical model predicts that with so many people being successfully treated, there will be less virus to transmit to others. But the latest global figures show more people are being diagnosed than are starting treatment.
It is impossible to know if we are hitting the first 90% because we do not have a defined target population. There are estimates that just 40% of Swazis know their status. And how often do people have to test? We treat anyone who comes through the doors and do over 7,000 HIV tests a year in our clinic.
I thought we were easily achieving the second 90%. Over 95% of our patients with an immune system damaged enough to warrant treatment complete three counselling sessions and start ART. Perhaps that is not the true picture as we don’t track those who test positive but fail to return for repeat testing to find out when they need to start ART.
But are these patients taking ART being successfully treated? The guidelines suggest that after six months of ART, we should check the patient’s viral load. If this and a second viral load test after another six months are both undetectable, we reduce the testing frequency to yearly. With almost 5,000 patients taking ART at the clinic, we do lots of tests. When we test depends on when the patient turns up for a refill of their medication, rather than adhering to a strict schedule.
It was my idea to check on two cohorts of patients – those whom we started on treatment a year ago and those who transferred into our service after April 2015. The first group would be having their viral load checked six months after initiating treatment and the second group have baseline tests including viral load as part of our induction procedure. All new patients on treatment are allocated a code number (P17A followed by four digits for original patients and transfer in patients get TI-followed by four digits), which made it easier to define the cohort. So I looked at consecutive patients with codes P17A4200 and TI-1280 onwards.
Like all good audits, it raised more questions than it provided answers. We are on track to reach 90% by 2020, with the more stable transferred in patients at 89% and our home-grown patients at 86%. We discovered that a batch of several hundred blood test results from August had vanished into the aether. We should be able to fix this with some detective work. However, the main problem I discovered was what we are not doing for those patients who have detectable viral loads. Only a third of failing patients had been enrolled in stepped up counselling. At the next NaHSAR meeting we will no doubt be reporting on how we tackled this issue.
When I told my Swazi colleagues at work about the results of my audit, they were dismayed. “But no one ever reports bad things at these meetings, docotela. You will be savagely criticised if you present this.” I refused to whitewash the report. I can justify what we have done and how we are trying to solve any problems. No one gets it right first time.
I was delighted to find out that for this NaHSAR meeting, teams of data collectors had visited clinics collecting raw data from handwritten ledgers. At the opening session, a representative of “Monitoring & Evaluation” said that was to reduce the numbers of facilities self-reporting 100% on the indicators. So perhaps we will get a true picture of what is happening. But holding the meeting in a casino is always a bit of gamble.