The Feasibility of Using Criteria to Identify Stable Patients on HAART at Themba Lethu Clinic

Abstract

Background: With recent increases in eligibility criteria to a CD4 count <350, South Africa has begun to see rapid growth in the number of patients on highly-active antiretroviral therapy (ART). The expanding number of patients is creating a substantial burden on HIV treatment staff and contributing to long waiting times for patients. HIV clinics are exploring ways to reduce the overall number of visits patients need to reduce the burden on staff. We sought to use routinely collected data to determine whether a simple screening tool could identify stable patients that would not need to see a clinician during a scheduled medical visit. Methods: The data for this analysis come from Themba Lethu, an HIV clinic in Johannesburg, South Africa that has more than 40,000 medical visits annually. Eligible visits were all visits after 6 months on ART. Stable medical visits were defined as having all of the following: stable or increasing CD4 count, undetectable viral load, stable weight, no new pregnancy or comorbidity, no regimen change within the last three months, and normal lab results for hemoglobin, ALT, and creatinine clearance. We identified stable visits from 1 January 2007 to 7 September 2011. We assessed the sensitivity and specificity of stable visits at predicting two indicators of disease progression or needing additional care: a) ART regimen change; and b) follow- up visits in < 3 weeks from previous visit. Results: Patients were 65% female and a median of 37 years old at ART initiation. A total of 143,474 eligible medical visits were made by 14,315 patients. Nearly 34% of visits were classified as stable and 75% of all patients had at least one stable visit. The most common reason for a visit not being stable was a declining CD4 count 51,217 (36%). A small proportion of stable visits 1.4% (N=668) resulted in an ART regimen being changed and 6.1% (N=2,662) of visits were in < 3 weeks. Stable visits had a sensitivity of 91.0% (95% CI 90.3- 91.6) and a specificity of 34.9% (34.7- 35.2) at predicting ART therapy changes, and a sensitivity of 78.2% (77.5- 78.9) and specificity of 35.1% (34.8- 35.4) for predicting a follow- up visit interval of < 3 weeks. Conclusions: Our criteria have the potential to reduce the number of medical visits while missing few visits in which changes in regimen or additional care would be needed. More research is needed to determine whether implementation of our method could reduce visits without compromising safety or loss to follow- up.

Conference: CROI 2012, Seattle, USA