title: Practices to improve identification of adult antiretroviral therapy failure at the Lighthouse Trust clinic in Lilongwe, Malawi.
abstract: OBJECTIVE
  Evaluating treatment failure is critical when deciding to modify antiretroviral therapy (ART). Virologic Assessment Forms (VAFs) were implemented in July 2008 as a prerequisite for ordering viral load. The form requires assessment of clinical and immunologic status.
  
  
  METHODS
  Using the Electronic Medical Record (EMR), we retrospectively evaluated patients who met 2006 WHO guidelines for immunologic failure (≥15 years old; on ART ≥6 months; CD4 count <baseline OR CD4 count >50% drop from peak OR CD4 persistently <100 cells) at the Lighthouse Trust clinic from December 2007 to December 2009. We compared virologic screening, VAF implementation and ART modification during the same period using Fisher's exact tests and unpaired t-tests as appropriate.
  
  
  RESULTS
  Of 7000 enrolled ART patients ≥15 years old with at least two CD4 counts, 10% had immunologic failure with a median follow-up time on ART of 1.4 years (IQR: 0.8-2.3). Forty (6%) viral loads were ordered: 14 (35%) were detectable (>400 HIV RNA copies/mL) and one (7%) patient was switched to second-line therapy. Overall, 259 VAFs were completed: 67% for immunologic failure and 33% for WHO Stage 4 condition. Before VAF implementation, 1% of patients had viral loads drawn during routine care, whereas afterwards, 8% did (P<0.0001; 95% CI: 0.03-0.08).
  
  
  CONCLUSIONS
  Clinicians did not identify a large proportion of immunologic failure patients for screening. Implementation of VAFs produced little improvement in virologic screening during routine care. Better training and monitoring systems are needed.
authors: UNC Project, Lilongwe, Malawi  Lighthouse Trust Clinic, Lilongwe, Malawi.
authors: Charles K
authors: CK
authors: Vorkas
authors: Hannock
authors: H
authors: Tweya
authors: Dalitso
authors: D
authors: Mzinganjira
authors: George
authors: G
authors: Dickie
authors: Ralf
authors: R
authors: Weigel
authors: Sam
authors: S
authors: Phiri
authors: Mina C
authors: MC
authors: Hosseinipour
mesh_terms: D000293:Adolescent; D000554:Ambulatory Care Facilities; D019380:Anti-HIV Agents / Q000627:therapeutic use*; D018791:CD4 Lymphocyte Count; D057286:Electronic Health Records; D005260:Female; D017408:Guidelines as Topic; D015658:HIV Infections / Q000188:drug therapy* / Q000276:immunology / Q000821:virology; D006801:Humans; D008295:Malawi; D008297:Male; D012189:Retrospective Studies; D017211:Treatment Failure; D019562:Viral Load; D014944:World Health Organization; D055815:Young Adult
chemical_list: D019380:Anti-HIV Agents