title: Feasibility of antiretroviral treatment monitoring in the era of decentralized HIV care: a systematic review.
abstract: BACKGROUND
  Regular monitoring of HIV patients who are receiving antiretroviral therapy (ART) is required to ensure patient benefits and the long-term effectiveness and sustainability of ART programs. Prompted by WHO recommendations for expansion and decentralization of HIV treatment and care in low and middle income countries, we conducted a systematic review to assess the feasibility of treatment monitoring in these settings.
  
  
  METHODS
  A comprehensive search strategy was developed using a combination of MeSH and free text terms relevant to HIV treatment and care, health service delivery, health service accessibility, decentralization and other relevant terms. Five electronic databases and two conference websites were searched to identify relevant studies conducted in LMICs, published in English between Jan 2006 and Dec 2015. Outcomes of interest included the proportion of patients who received treatment monitoring and health system factors related to monitoring of patients on ART under decentralized HIV service delivery models.
  
  
  RESULTS
  From 5363 records retrieved, twenty studies were included in the review; all but one was conducted in sub-Saharan African countries. The majority of studies (15/20) had relatively short follow-up duration (≤24 months), and only two studies were specifically designed to assess treatment monitoring practices. The most frequently studied follow-up period was 12 months and a wide range of treatment monitoring coverage was observed. The reported proportions of patients on ART who received CD4 monitoring ranged from very low (6%; N = 2145) to very high (95%; N = 488). The median uptake of viral load monitoring was 86% with studies in program settings reporting coverage as low as 14%. Overall, the longer the follow-up period, the lower the proportion of patients who received regular monitoring tests; and programs in rural areas reported low coverage of laboratory monitoring. Moreover, uptake in the context of research had significantly better where monitoring was done by dedicated research staff. In the absence of point of care (POC) testing, the limited capacity for blood sample transportation between clinic and laboratory and poor quality of nursing staff were identified as a major barrier for treatment monitoring practice.
  
  
  CONCLUSIONS
  There is a paucity of data on the uptake of treatment monitoring, particularly with longer-term follow-up. Wide variation in access to both virological and immunological regular monitoring was observed, with some clinics in well-resourced settings supported by external donors achieving high coverage. The feasibility of treatment monitoring, particularly in decentralized settings of HIV treatment and care may thus be of concern and requires further study. Significant investment in POC diagnostic technologies and, improving the quality of and training for nursing staff is required to ensure effective scale up of ART programs towards the targets of 90-90-90 by the year 2020.
authors.affiliation: Burnet Institute, 85 Commercial Road, Melbourne, VIC, 3004, Australia.|Department of Epidemiology and Preventive Medicine, Faculty of Medicine Nursing and Health Science, Monash University, Melbourne, Australia.
authors.forename: Minh D
authors.initials: MD
authors.lastname: Pham
authors.affiliation: The Alfred Hospital, The Ian Potter Library, Melbourne, VIC, Australia.
authors.forename: Lorena
authors.initials: L
authors.lastname: Romero
authors.affiliation: Burnet Institute, 85 Commercial Road, Melbourne, VIC, 3004, Australia.
authors.forename: Bruce
authors.initials: B
authors.lastname: Parnell
authors.affiliation: Burnet Institute, 85 Commercial Road, Melbourne, VIC, 3004, Australia.|Department of Microbiology, Faculty of Medicine Nursing and Health Science, Monash University, Melbourne, Australia.
authors.forename: David A
authors.initials: DA
authors.lastname: Anderson
authors.affiliation: Burnet Institute, 85 Commercial Road, Melbourne, VIC, 3004, Australia.|Department of Infectious Diseases, The Alfred Hospital Melbourne, Melbourne, Australia.|Monash School of Medicine, Faculty of Medicine Nursing and Health Science, Monash University, Melbourne, Australia.
authors.forename: Suzanne M
authors.initials: SM
authors.lastname: Crowe
authors.affiliation: Burnet Institute, 85 Commercial Road, Melbourne, VIC, 3004, Australia. stanley.luchters@burnet.edu.au.|Department of Epidemiology and Preventive Medicine, Faculty of Medicine Nursing and Health Science, Monash University, Melbourne, Australia. stanley.luchters@burnet.edu.au.|International Centre for Reproductive Health, Department of Obstetrics and Gynecology, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium. stanley.luchters@burnet.edu.au.
authors.forename: Stanley
authors.initials: S
authors.lastname: Luchters
mesh_terms: D019380:Anti-HIV Agents / Q000008:administration & dosage*; D018791:CD4 Lymphocyte Count; D016903:Drug Monitoring / Q000379:methods*; D015658:HIV Infections / Q000188:drug therapy* / Q000821:virology; D015497:HIV-1 / Q000302:isolation & purification; D006297:Health Services Accessibility; D006801:Humans; D016032:Randomized Controlled Trials as Topic; D019562:Viral Load
chemical_list: D019380:Anti-HIV Agents
keywords: Antiretroviral treatment; CD4; Decentralized care; HIV; Systematic review; Task-shifting; Treatment monitoring; Viral load