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Author Notes:


JB was the principal investigator in the study and contributed to study implementation, data collection, data analysis and writing up all versions of the manuscript. YZ has contributed to data analysis and interpretation. JE 1) was the initial point person for the cleaning of collected data in preparation for analyses. 2) was the initial point person for exploratory analyses of the data. 3) contributed to the structure, format, and design of the figures presented in the final manuscript. 4) Additionally, I was a contributor to the interpretation of final analyses appearing in the manuscript. 5) co-wrote and edited all versions of this manuscript and the supplemental section. BAJ helped with the data analysis, data interpretation, writing, tables and Figures. PM Collaborator on study and involved in drafting, reviewing and editing manuscript. KP Made physical site visits for quality improvement processes and Contributed in data compilation, data analysis and data interpretation. SP contributed toward study design, implementation, data collection and manuscript review. KGC Intellectual contribution to discussions during early study design/implementation and subsequent analysis and interpretation of data. HS Design of the study protocol and tools Regular input into the quality and manner of its implementation. Critical Review of the script. DRK contributed to study design, data interpretation, acquiring funding for the project and editorial review of the manuscript. MYSM study design, data interpretation, writing and reviewing manuscript. VCM Grant support, study design and implementation, data analysis and interpretation, figures/tables, manuscript drafting and review. All authors have read and approved the manuscript.

We would like to express our deepest admiration and appreciation for the patients who participated in the parent study and the work of the Bethesda District Hospital Clinic, Jozini Clinic, and Mkuze Clinic in the uMkhanyakude Health District, KZN, South Africa for their commitment to improve patient care and support research. The tremendous contributions on the part of the medical records staff, nurses, and medical officers have been essential to the success of this study. Maneesha Chitnavis, Dr. Kelly Gates, Dr. Cyril Nkabinde, Dr. Nompumelelo Gloria Nkabinde, Dr. Jacinth Mudaly, Ansuri Singh, Sajiv Pertab, Buhle Zuma, Nomzamo Mbatha, Nomathemba B Zungu, Sithembile Mafuleka and Sifiso Shange provided vital assistance for the intervention and data collection.

No competing interests were declared among the authors of this paper. D.R.K. has received consulting honoraria and/or research support from AbbVie, Gilead, GlaxoSmithKline, Janssen, Merck and ViiV. V.C.M. has received consulting honoraria and/or research support from Lilly, ViiV, Gilead and Bayer.


Research Funding:

The parent study was supported by the Emory University Centre for AIDS Research (CFAR) for salary support (V.C.M., P30AI050409) and NIH/NIAID for salary support and funding the parent study ADReSS (V.C.M. and D.R.K R01 AI098558).


  • Science & Technology
  • Life Sciences & Biomedicine
  • Infectious Diseases
  • HIV
  • Viral load
  • South Africa
  • Rural health
  • Virologic suppression
  • Monitoring
  • RISK

A packaged intervention to improve viral load monitoring within a deeply rural health district of South Africa

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Journal Title:



Volume 20, Number 1


, Pages 836-836

Type of Work:

Article | Final Publisher PDF


Background: The KwaZulu-Natal (KZN) province of South Africa has the highest prevalence of HIV infection in the world. Viral load (VL) testing is a crucial tool for clinical and programmatic monitoring. Within uMkhanyakude district, VL suppression rates were 91% among patients with VL data; however, VL performance rates averaged only 38·7%. The objective of this study was to determine if enhanced clinic processes and community outreach could improve VL monitoring within this district. Methods: A packaged intervention was implemented at three rural clinics in the setting of the KZN HIV AIDS Drug Resistance Surveillance Study. This included file hygiene, outreach, a VL register and documentation revisions. Chart audits were used to assess fidelity. Outcome measures included percentage VL performed and suppressed. Each rural clinic was matched with a peri-urban clinic for comparison before and after the start of each phase of the intervention. Monthly sample proportions were modelled using quasi-likelihood regression methods for over-dispersed binomial data. Results: Mkuze and Jozini clinics increased VL performance overall from 33·9% and 35·3% to 75·8% and 72·4%, respectively which was significantly greater than the increases in the comparison clinics (RR 1·86 and 1·68, p < 0·01). VL suppression rates similarly increased overall by 39·3% and 36·2% (RR 1·84 and 1·70, p < 0·01). The Chart Intervention phase showed significant increases in fidelity 16 months after implementation. Conclusions: The packaged intervention improved VL performance and suppression rates overall but was significant in Mkuze and Jozini. Larger sustained efforts will be needed to have a similar impact throughout the province.

Copyright information:

© The Author(s) 2020

This is an Open Access work distributed under the terms of the Creative Commons Attribution 4.0 International License (https://creativecommons.org/licenses/by/4.0/rdf).
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