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    Trend of Pre-antiretroviral Therapy HIV-1 Drug Resistance in Kilombero and Ulanga Antiretroviral Cohort, South-Western Tanzania, for over 15 years (2005-2020)
    (University of the Witwatersrand, Johannesburg, 2024) Ntamatungiro, Alex; Kagura, Juliana
    Introduction Pre-treatment HIV drug-resistance (PDR) may result in increased risk of virological failure and subsequently acquisition of new HIV drug resistant mutations. With recent increase in antiretroviral therapy (ART) coverage and periodic modifications of the guidelines for HIV treatment, monitoring changes in levels of PDR is critical, particularly in under-sampled areas, such as rural Tanzania. This PhD project aimed to determine the trend and patterns of PDR in the Kilombero and Ulanga antiretroviral cohort (KIULARCO), analyse the impact of recent HIV-1 infection, and dolutegravir rollout in rural Tanzania. Methods The study comprised a systematic review and meta-analysis of primary studies about prevalence of PDR among ART-naive people living with HIV (PLHIV) (³15 years old), published between 2017 and 2022. The data had to be in one or several of the countries of Eastern Africa, namely, Ethiopia, Kenya, Malawi, Rwanda, Mozambique, Tanzania, and Uganda. Thereafter, cross- sectional analyses of data on newly HIV-1-diagnosed ART-naïve adults (aged ≥ 15 years), enrolled in the on-going prospective clinic-based observational rural antiretroviral cohort- KIULARCO focusing on various aspects of PDR. Multivariate logistic regressions were used to determine the factors associated with recent HIV-1 infection, and viral suppression at 12-months in patients initiating dolutegravir-based ART in the KIULARCO. Results Overall, the pooled prevalence estimate of any PDR was 10.0% (95% CI: 7.9%–12.0%, I2 =88.9%) among 22 studies in the general adults’ population, which was higher than the previously reported prevalence of 8.7% using data available until 2016 in the Eastern Africa region. PDR was mainly driven by non-nucleoside reverse transcriptase inhibitors (NNRTI); whereas the pooled prevalence of PDR to nucleoside reverse transcriptase inhibitors (NRTI) was 2.6% (95% CI: 1.8%–3.4%, I2=69.2%). Remarkably, PDR to NRTIs in a sub-population of recently HIV-1 infected PLHIV in the KIULARCO was high at 12.5%. Also, there was a notable tendency to an increasing prevalence of PDR to NRTI, with the overall prevalence of 2.1% in the first five-year period (2005-2009) of the ART program in Tanzania, and 3.4 % in the most recent period (2019-2022). Moreover, there was no PDR to the dolutegravir co-administered NRTI in those with viremia ≥50 copies/mL, at one year, in patients initiating dolutegravir-based ART in the KIULARCO 2 years after dolutegravir roll. Notably, dolutegravir-based ART was associated with >2 times the odds of viral suppression compared to NNRTI-based ART with an adjusted odds ratio (aOR) of 2.10 (95% CI 1.12-3.94). Conclusions There is notable level of PDR to NRTI among general adults’ population in Eastern Africa region, that was high among recently HIV-1 infected PLHIV in a representative rural Sub-Saharan Africa setting. Hence, routine surveillance of pre-existing resistance to the DTG co-administered NRTI remains particularly important, in resource-limited settings, to prevent risk of failure of newer antiretroviral agents such as dolutegravir, which would be detrimental to Tanzania and other low- and middle-income countries for the aim to “end AIDS by 2030”. Our results underline the benefit of programmatic uptake of dolutegravir -based ART in low- and middle-income countries.
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    Nurses’ experiences in implementing Nurse Initiated Management of Anti-Retroviral Therapy (NIMART) in primary health care facilities in Dr Ruth Segomotsi Mompati District, North West Province
    (2024) Sibisi, Nthabiseng
    Aim of study- This study aimed to explore the nurses’ experiences in the implementation of NIMART in Dr Ruth Segomotsi Mompati District since its inception in 2010 to 2017. Methods This study employed an exploratory qualitative research design. The study setting included nine PHC facilities in three sub-districts. The study included only those nurses who had been trained to implement the NIMART in the district PHC facilities from 2010-2017. The final sample included Sixteen (16) nurses, comprising of three males and thirteen females from the three eight-hour operational clinics and six 24-hour Community Health Centres (CHCs). Data were therefore collected using in-depth interviews lasting thirty-five minutes (minimum) one and half hours 1h30 minutes (maximum). These interviews were guided by a semistructured interview guide. Data were later transcribed verbatim using an electronic software O’ Transcribe, and then analysed using MAXQDA 2018v, where inductive coding was applied. Thematic analysis was employed to interpret and represent data, which was finally presented as themes based on participants’ dominant narratives. Results- There were five key themes that emerged from this study. These included: perceptions about the NIMART programme mostly related to it being a task-shifting strategy when managing HIV and Aids and the programme benefits; contextual elements affecting access and adherence to NIMART, and challenges such as socio-cultural factors, social norms, socio-political and governance factors; facilitators of NIMART implementation in terms of functional health information management system and clinical guidelines, multidisciplinary team and skilled personnel, impactful counselling services, and intrinsic nurse motivators. Challenges of NIMART implementation included insufficient human resources for health, services integration, poor management and health-service support systems, lack of capacity building, ART unavailability and poor patient compliance to ART, and nurse demotivation. The proposed interventions by the nurses included provision of training, increasing staff to curb workload, management support, and debriefing, health service support resources and patient support improvement. Conclusion Task-shifting and successful NIMART implementation are complex notions, which can be successful if accompanied by training, reorganisation of services, mentoring, supervision, and ongoing support from existing health-service system structures. The rural health context must be considered as unique, and policies should be tailored to suit the needs of rural healthcare workers and patients. Dr RSM case-study has shows the plight of farm labourers and the need for a multisectoral approach to address patient related issues in this context. The challenges to successful NIMART implementation suggest a need for reorientation of health-services to fit rural contexts.