HIV Drug Resistance in South Africa: Capacitating Local Public Health Managers to Identify Early Warning Signs

JPS Africa is collaborating and supporting the World Health Organization (WHO) and the National Department of Health and in undertaking HIV Drug Resistance (HIVDR) surveillance across provinces in South Africa.

In recent years, the rapid scale up of ART for HIV infection in resource-limited countries has been identified as an international healthcare priority. Sub-Saharan Africa remains the most affected region with a total of 24.7 million which is 73% of the total number of people estimated to be living with HIV around the globe. At the end of 2015, SANAC estimated that 6.4 million South Africans are living with HIV with approximately 2.8 million on anti-retroviral therapy. Scaling-up ART in SA comprises the use of standardized and simplified treatment regimens that are consistent with international guidelines. The emergence and transmission of HIV drug resistance (HIVDR) is an unavoidable consequence of ART, even when appropriate drugs are prescribed and adherence is maximally supported.

Early warning indicators (EWIs) of HIV drug resistance are a key component of the World Health Organization public health strategy to minimize and assess HIVDR in countries scaling up antiretroviral therapy (ART). EWIs are quality of care indicators which specifically assess factors associated with emergence of HIVDR at individual antiretroviral therapy clinics. Monitoring EWIs alerts Local and Provincial ART programme managers to clinic factors that need increased attention to reduce the potential for significant population-level virological failure and emergence of preventable HIVDR.

The consequence of HIVDR has significant impact on long-term efficacy of local and national ART programmes. Prevalence of <5% drug resistance (DR) is somewhat expected at a population level, which could be curbed without having a negative impact on the national ART programme. HIVDR of 5-15% is high alert for requiring urgent action in addressing site-level factors favorable to the development of HIVDR. DR of >15% is indicative of a failing ART programme.

Routine EWI monitoring alerts clinic and district managers to specific areas which require attention and supports overall optimization of patient care. Currently, 68 countries are undertaking the process of HIVDR EWI surveillance. This process was introduced to South Africa in July 2014 where Public Health Officials were orientated on the nature and consequence of unchecked emergence of HIVDR.


Recently, from July 2015 this process has been implemented in SA across 5 provinces. JPS Africa is providing support in the training of public health officials on EWIs as well as in-the-field support to districts in undertaking this EWI process at facility-level, and providing expertise in data consolidation, interpretation and recommendations for action to provincial and district public health officials. Following the training and support, local health officials and clinic managers are able to interpret their surveillance findings, identify trends and decide on appropriate actions to mitigate HIV drug resistance in their communities. Furthermore, districts are supported to undertake this process routinely, which builds local and national data on quality of clinical care and emergence of drug resistance which subsequently provides an evidence base for policy and management directives.




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