Résumé
With the rapid scale-up in use of antiretroviral therapy (ART), monitoring the quality of care and factors that may lead to emergence of HIV drug resistance (HIVDR) is an important focus point for programme managers. The National AIDS Control Organisation of India embarked on strengthening the ART programme for continuous quality improvement (CQI), using defined quality-of-care indicators (QCIs), including World Health Organization (WHO) early-warning indicators (EWIs) for HIVDR. In this feasibility study, done during July 2014, an integrated QCI and EWI tool developed by WHO India was pilot tested across 18 purposively selected ART centres. At seven ART centres, the EWI 1 target of >90% on-time pill pick-up was achieved for adult patients, while among the paediatric age group (<15 years old) it was not achieved by any centre. EWI 2 (retention of patients in ART care at 12 months after initiation) showed that two centres had retention of both adult and paediatric patients of >85% at 12 months of ART, while 11 centres had retention between 75% and 85%. EWI 3 (pharmacy stock-out) for adult and paediatric patients showed that 11 ART centres reported a minimum of one stock-out for the first-line ART drugs in the reporting period, while EWI 4 targets (pharmacy dispensing practices) were achieved by all the centres, for both adults and children. Average retention in care at 6, 12 and 24 months after ART initiation was 82%, 77% and 71%, respectively. This feasibility study showed that EWI analyses were much simpler to conduct if information was sought only for patients receiving ART, for whom the quality of record-keeping is better and more consistent. The activity has highlighted the need for improved quality of recordkeeping at the facilities and implementation of specific interventions to ensure better patient follow-up. After modifications, use of the tool will be phased in across all the ART centres in India.
Résumé
Background: India has rapidly scaled up its programme for antiretroviral therapy (ART). There is high potential for the emergence of HIV drug resistance (HIVDR), with an increasing number of patients on ART. It is not feasible to perform testing for HIVDR using laboratory genotyping, owing to economic constraints. This study piloted World Health Organization (WHO) early-warning indicators (EWIs) for HIVDR, and quality-of-care indicators (QCIs), in four ART clinics in Pune city. Methods: A retrospective study was conducted in 2015, among four ART clinics in Pune city, India. The data on four standardized EWIs (EWI 1: On-time pill pickup, EWI 2: Retention of patients in ART care at 12 months after initiation, EWI 3: Pharmacy stock-out, EWI 4: Pharmacy dispensing practices) and three QCIs (QCI 1: Regularity in CD4 testing in patients taking ART, QCI 2: Percentage of patients initiating ART within 30 days of medical eligibility, QCI 3: Percentage of patients initiating ART within 30 days of initiation of anti-tuberculosis therapy) were abstracted into WHO Excel HIV data abstractor tools, from the patient records from April 2013 to March 2014. Results: All four ART clinics met the EWI 4 target (100%) for ART dispensing practices. The target for EWIs on-time pill-pick (EWI 1 >90%) and pharmacy stockouts (EWI 3: no stock-outs, 100%) were achieved in one clinic. None of the clinics met the EWI 2 target for retention in care at 12 months (>90%) and the overall retention was 76% (95% confidence interval: 73% to 79%). The targets for QCI 1 and QCI 2 (>90% each) were achieved in one and two clinics respectively. None of the clinics achieved the target for QCI 3 (>90%). Conclusion: ART dispensing practices (EWI 4) were excellent in all clinics. Efforts are required to strengthen retention in care and timely pill pick-up and ensure continuity of clinic-level drug supply among the programme clinics in Pune city. The clinics should focus on regularity in testing CD4 count and timely initiation of ART.