Challenges with targeted viral load testing for medical inpatients at Queen Elizabeth Central Hospital in Blantyre, Malawi|
Craik, Alison; Patel, Priyanka; Patel, Pratiksha; Mallewa, Jane; Malisita, Ken; Bitilinyu-Bangoh, Joseph; van Oosterhout, Joep J. & Kelly, Christine
Approximately 75% of medical inpatients at Queen Elizabeth Central Hospital (QECH) in Blantyre, Malawi are HIV seropositive, and a
third of these patients are on antiretroviral therapy (ART). Malawi guidelines recommend targeted viral load (VL) testing for patients on
ART for at least one year who report excellent adherence and present with a WHO clinical stage 3 or 4 HIV disease. A switch to secondline
ART is only indicated if a VL result >5000 copies/mL confirms treatment failure.
During an audit of targeted VL testing at QECH, all adult medical admissions were screened to identify those in need of VL testing.
Daily review of inpatient notes ascertained whether VL testing was ordered and carried out. At 8 weeks post-discharge the laboratory
database was checked for results and was triangulated with the HIV outpatient database to ascertain whether patients had attended clinic,
received results, and if these results had been acted upon.
Out of 81 patients recruited, 63 (77%) had a VL requested. At 8 weeks post-discharge, nine patients (14%) had VL results available. The
median (IQR) waiting time for those with results was 29 days (20-47). Five patients had a VL >5000 copies/mL. Of these patients, three
attended clinic and one was switched to second-line ART. Of the remaining 55 patients awaiting results, the median (IQR) waiting time
at the 8-week follow-up point was 72 days (67-80). At 8 weeks post-discharge, 8 patients (33%) had died.
Our findings demonstrate challenges with targeted VL testing at QECH. Only two-thirds of patients with clinical ART failure were
identified as eligible for targeted VL testing, and of these less than one-sixth had VL results available after 8 weeks. Interventions such as
point-of-care targeted VL testing could result in faster turnaround times. In the interim, we suggest further evaluation of the possibility
of switching patients with clinical ART failure and a low CD4 count to second-line ART while awaiting VL results.