Trends and determinants of ART patient monitoring practices in Kenya, Uganda and Zambia

Abstract

Background: Immunological and clinical measurements are the primary means of monitoring patients receiving antiretroviral therapy (ART) for treatment failure. It is unknown to what extent long-standing WHO and national CD4 and weight monitoring guidelines have been adopted in practice. Methods: Using data extracted from the charts of 32,540 ART patients at 146 facilities in Kenya, Ugandan and Zambia we descriptively analyzed the availability of immunological and clinical information at baseline, and the percent of established patients meeting weight and CD4 guidelines from 2009-2011. We used mixed effects logistic regressions to assess facility and patient factors associated with meeting monitoring guidelines. Counterfactual scenarios were examined to evaluate the relative importance of inadequate care seeking and inadequate facility provision of testing. Results: Baseline WHO stage and weight measurements were available for over 90% of the most recently initiating cohorts, while 80% had a CD4 measurement and <1 had a viral load. A more advanced WHO stage was associated with lower odds of baseline CD4 testing. An average of 40% and 70% of established patients met CD4 and weight guidelines, respectively. Established CD4 testing was lowest at rural clinics. In Uganda, established patient with previous signs of clinical failure and immunological failure were more likely to meet guidelines. Inadequate patient visiting limited CD4 and weight monitoring at rural clinics. Inadequate facility provision limited CD4 monitoring at all facility types. Discussion: Most patients met weight guidelines during the study period, but less than half met CD4 guidelines. CD4 monitoring was limited by both inadequate visiting and insufficient testing by facilities at rural clinics. Infrequent CD4 monitoring suggests inadequate use of immunological failure criteria and raises concerns about the feasibility of implementing viral load programs.