How accurately do routinely reported HIV viral load suppression proportions reflect progress towards the 90-90-90 target in the population on antiretroviral treatment in Khayelitsha, South Africa?

Background. The Joint United Nations Programme on HIV/AIDS (UNAIDS) third 90-90-90 target requires 90% of patients on antiretroviral treatment (ART) to be virally suppressed (<1 000 copies/mL). In Khayelitsha, Cape Town, South Africa viral load (VL) suppression of <400 copies/mL was reported as 89% in 2016, but only 56% of patients had a result recorded in routine data. We conceived a VL 'cascade' to represent the steps required for an expected VL to be reported as complete in routine data and thus contribute to reported VL suppression: among those for whom a VL is 'expected', a sample must be collected and tested ('done'), a result must be 'filed' in the patient folder, 'noted' by a clinician and electronically 'captured'. The low reported completion suggested gaps along the VL cascade and cast doubt on the validity of reported suppression.Objectives. To assess the validity of routinely reported VL suppression and identify barriers to VL completion. Methods. A retrospective cohort study between 1 July 2015 and 30 June 2016, which included all Khayelitsha patients receiving ART, with a routine VL expected, was conducted. We obtained data routinely captured on site and VL data from the laboratory system. A sample of 1 035 patient folders was reviewed. VL suppression was calculated using laboratory data, including all tests done, and compared with reported suppression based on on-site captured electronic data. Successful progression through each step on the VL cascade was estimated. We used logistic regression to identify factors associated with laboratory data and reported VL testing.Results. Of 22 991 patients for whom a routine VL test was due, 84% were done, 79% filed, 76% noted and 55% captured. Using all laboratory data, VL suppression was estimated as 82%, 87%, 89% and 91% at the 50, 200, 400 and 1 000 copies/mL thresholds, respectively, but reported suppression using captured results was 80%, 86%, 88% and 89% at those thresholds. Routine VL testing is more likely to be done in children <15 years old (adjusted odds ratio (aOR) 1.89, 95% confidence interval (CI) 1.45 - 2.48) and pregnant women (aOR 1.90, 95% CI 1.28 - 2.81) than in men, adjusted for facility. Conclusions. Despite a low reported completion, VL testing completion was high. Reported suppression using captured data was similar to suppression calculated using all laboratory data, which provided an accurate measure of progress towards the 90-90-90 target. More work is needed to reach the 16% of patients missed by routine testing

Clinician Compliance with Laboratory Monitoring and Prescribing Guidelines in HIV-1-Infected Patients Receiving Tenofovir

BACKGROUND:Tenofovir is part of the preferred first-line regimen for HIV-infected patients in South Africa (SA); but is associated with kidney toxicity. SA antiretroviral therapy (ART) guidelines recommend creatinine monitoring at baseline (ART start) and at 3; 6 and 12 months; and substituting tenofovir with zidovudine; stavudine or abacavir should creatinine clearance (CrCl) decrease to etlt;50 mL/min. OBJECTIVE:To assess clinician compliance with tenofovir monitoring and prescribing guidelines.METHODS:We described the proportion of adult patients on tenofovir-based first-line ART who were screened for baseline renal impairment; were monitored according to the SA antiretroviral treatment guidelines; and were switched from tenofovir if renal function declined.RESULTS:We included 13 168 patients who started ART from 2010 to 2012. Creatinine concentrations were recorded in 11 712 (88.9%) patients on tenofovir at baseline; 9 135/11 657 (78.4%) at 3 months; 5 426/10 554 (51.4%) at 6 months; and 5 949/ 8 421 (70.6%) at 12 months. At baseline; 227 (1.9%) started tenofovir despite a CrCl etlt;50 mL/min. While on tenofovir; 525 patients had at least one CrCl of etlt;50 mL/min. Of 382 patients with =3 months' follow-up after a CrCl etlt;50 mL/min; 114 (29.8%) stopped tenofovir within 3 months. Clinicians were more likely to stop tenofovir in patients with lower CrCl and CD4 count. Of 226 patients who continued to receive tenofovir and had further CrCls available; 156 (69.0%) had a CrCl =50 mL/min at their next visit.CONCLUSIONS:Creatinine monitoring is feasible where access to laboratory services is good. Kidney function recovered in most patients who continued to receive tenofovir despite a CrCl etlt;50 mL/min. Further research is needed to determine how best to monitor renal function with tenofovir in resource-limited settings

Chlamydia Infection; Plasma Peroxidation and Obesity in Tubal Infertility

Background: Genital tract infections and obesity are both sources of oxidative stress. Alterations in immune and antioxidant parameters may arise from this or from an indeterminate autoimmune mechanism. Objective: This study aimed to investigate the association of Chlamydial infection; obesity and oxidative response with tubal infertility in Nigerian women. Methods: It was a case-control study of 40 women with tubal infertility and 32 fertile women; respectively; recruited from the Infertility and Family Planning Clinics respectively; of the University College Hospital; Ibadan; Nigeria. Anthropometric indices were measured in each subject and endocervical swabs were taken to screen for current genital tract infection. Antioxidant; hormonal and immunologic analysis were performed on serum. Results: None of the subjects had current genital tract infections. Chlamydia trachomatis IgG positivity was significantly higher in infertile than in fertile subjects [OR 4.33; 95CI (0.078-0.681)]. No significant variations were observed in the anthropometric indices; antioxidant parameters and hormones between infertile and the fertile women. Body mass index correlated positively with oxidative stress in infertile subjects. Waist and hip circumferences correlated negatively with oestradiol in women with tubal infertility. Conclusion: Chlamydial infection is associated with tubal factor infertility; however; obesity seems to increase oxidative stress and reduce fertility potential in women with tubal factor infertility