Investigating the quality of HIV rapid testing practices in public antenatal health care facilities, South Africa

Abstract Monitoring HIV prevalence using antenatal HIV sentinel surveillance is important for efficient epidemic tracking, programme planning and resource allocation. HIV sentinel surveillance usually employs unlinked anonymous HIV testing which raises ethical, epidemiological and public health challenges in the current era of universal test and treat. The World Health Organization (WHO) recommends that countries should consider using routine prevention of mother-to-child transmission of HIV (PMTCT) data for surveillance. We audited antenatal care clinics to assess the quality of HIV rapid testing practices as the first step to assess whether South Africa is ready to utilize PMTCT programme data for antenatal HIV surveillance. In 2017, we conducted a cross-sectional survey in 360 randomly sampled antenatal care clinics using the adapted WHO Stepwise-Process-for-Improving-the-Quality-of-HIV-Rapid-Testing (SPI-RT) checklist. We calculated median percentage scores within a domain (domain-specific median score), and across all domains (overall median percentage scores). The latter was used to classify sites according to five implementation levels; (from 0:<40% to 4: 90% or higher). Of 346 (96.1%) facilities assessed, an overall median percentage score of 62.1% (inter-quartile range (IQR): 50.8–71.9%) was obtained. The lowest domain-specific median percentage scores were obtained under training/certification (35% IQR: 10.0–50.0%) and external quality assurance (12.5% IQR: 0.0–50.0%), respectively. The majority (89%) of sites had an overall median score at level 2 or below; of these, 37% required improvement in specific areas and 6.4% in all areas. Facilities in districts implementing the HIV Rapid Test Quality Improvement Initiative and supported by the President’s Emergency Plan for AIDS Relief (PEPFAR) had significantly higher median overall scores (65.6% IQR: 53.9–74.2%) (P-value from rank sum test: <0.001) compared with non–PEPFAR–supported facilities (56.6% IQR:47.7–66.0%). We found sub-optimal implementation of HIV rapid testing practices. We recommend the expansion of the PEPFAR-funded Rapid Test Continuous Quality Improvement (RTCQI) support to all antenatal care testing sites.

摘要 利用产前HIV哨点监测追踪HIV流行率，对于高效开展疫情监测、项目规划与资源配置具有重要意义。HIV哨点监测通常采用无关联匿名HIV检测方式，但在当前全面检测即治疗的时代背景下，该模式会引发伦理、流行病学与公共卫生层面的多重挑战。世界卫生组织（World Health Organization, WHO）建议各国考虑将常规艾滋病母婴传播预防（Prevention of Mother-to-Child Transmission of HIV, PMTCT）数据用于监测工作。本研究对产前保健诊所开展审核，以评估HIV快速检测操作的质量，作为评估南非是否具备利用PMTCT项目数据开展产前HIV监测能力的第一步。2017年，本研究依托经调整的WHO HIV快速检测质量提升分步流程（Stepwise-Process-for-Improving-the-Quality-of-HIV-Rapid-Testing, SPI-RT）核查表，在360家随机抽取的产前保健诊所中开展横断面调查。本研究分别计算了各领域内的中位百分比得分（领域特异性中位得分）以及所有领域的整体中位百分比得分，并以整体中位得分将检测点划分为5个实施等级：等级0对应得分<40%，等级4对应得分≥90%。在完成评估的346家机构（占抽样总数的96.1%）中，整体中位百分比得分为62.1%（四分位距IQR：50.8~71.9%）。领域特异性中位得分最低的两项分别为培训/认证领域（35%，IQR：10.0~50.0%）与外部质量保证领域（12.5%，IQR：0.0~50.0%）。多数（89%）检测点的整体中位得分处于等级2及以下；其中37%的检测点需在特定领域提升质量，6.4%的检测点则需在全领域开展改进。与未接受美国总统艾滋病紧急救援计划（President’s Emergency Plan for AIDS Relief, PEPFAR）支持的机构（56.6%，IQR：47.7~66.0%）相比，实施HIV快速检测质量提升项目且获得PEPFAR支持的辖区内机构，其整体中位得分显著更高（65.6%，IQR：53.9~74.2%；秩和检验P值<0.001）。本研究发现HIV快速检测操作的实施质量未达最优水平，因此建议将PEPFAR资助的快速检测持续质量改进（Rapid Test Continuous Quality Improvement, RTCQI）支持服务扩展至所有产前保健检测点。