'Know your CD4' campaign improves knowledge of HIV status, treatment initiation in Tanzania

A large-scale drive to improve knowledge of CD4 cell counts among people receiving HIV care in a Tanzanian district resulted in increased uptake of CD4 testing, an increase in treatment initiation and an improvement in patient retention, Tanzanian researchers reported at the HIV Implementers’ meeting earlier this month in Namibia.

Late initiation of treatment remains a major challenge in developing countries, despite a WHO recommendation that treatment should be initiated before the CD4 cell count falls below 200, wherever CD4 counting is available and resources permit.

Treatment providers in Tanzania identified lack of CD4 testing and lack of knowledge of CD4 count by clinicians and patients as a barrier to timely initiation of treatment, and developed an intervention to improve the use of CD4 counts in clinical decision-making and raise awareness of the value of knowing one’s CD4 count among patients.

AIDSRelief Tanzania launched a “Know Your CD4 Campaign” to counter the absence of CD4 counts. Treatment providers estimated that around 3000 people eligible for treatment were not on treatment. These were the target population for the campaign.

The campaign took place over a period of three weeks in the Tanga Region, which has nine hospitals, twelve health centres and three CD4-counting machines. Eighteen sites were covered and three additional CD4-counting machines provided.

The organisation comprised 17 people (nurses, adherence support, and pharmacy (two staff); laboratory workers (two staff); doctors (five); programme staff (four) and community-based health workers (four)). The primary objectives were to improve clinical systems and care; improve staff education and training (emphasising national guidelines that require CD4 counts, laboratory testing and staging), and increase patient ownership with an emphasis on participation in their own healthcare.

The campaign consisted of a multidisciplinary approach to address the challenges:

• Triaging – a patient was sent for CD4 count if it was not in their chart.
• Pharmacy – assurance of adequate drugs on-site to treat newly identified, eligible people.
• Community mobilisation efforts included sensitisation campaigns with a focus on stigma reduction and the importance of disclosure; understanding what a CD4 count meant and encouragement to request testing; promotional T-shirts and pens; training people living with HIV and community volunteers as CD4 ambassadors (a buddy system); health education sessions in clinic; support group meetings.
• Distribution of brochures at voluntary counselling and testing and TB centres emphasising the importance of referring HIV-positive patients to a clinic for follow-up and staging.
• Clinic staff were re-educated on the importance of CD4 counts.
• Laboratory: an inventory of laboratory equipment; revised laboratory policies and procedures including joint meetings between laboratory personnel and administration to educate them about procedures. Co-ordination meetings at each hospital and among all hospitals took place at which the daily capacity of the CD4-counting machine was discussed, the number of samples per site was quantified, and planning for the best utilisation of available laboratory capacity and sample transportation was discussed, with the allocation of specific days on which particular sites would send samples.
• Better communication with the laboratories and flagging of patient files alerted clinicians to the availability of CD4 results.

Outcomes included improved flow of patients through the clinic. Regular meetings between care and treatment clinic staff with laboratory personnel improved communication and teamwork. Patients became more knowledgeable about their care, and the introduction of a buddy system served to reinforce patient involvement in their own care.

Within the laboratories, instruments were used to maximum capacity, specimen handling improved and the number of specimens from each site increased. Co-operation among laboratory staff from different sites also improved.

The number of CD4 samples increased by 114% from May (3585 samples) to October 2007 (7698 samples). Test results prior to the campaign took two to three days, whereas now results are received on the same day. Patient retention increased from 69% in December 2007 to 72% in February 2008. ART enrollment increased by 62% between June and September 2007.

The campaign resulted in clinicians beginning ART earlier and more closely monitoring their patients, who in turn were more involved and knowledgeable about their own care. The number of CD4 tests and people on ART increased considerably. The CD4 campaign has been replicated successfully in Zambia and Kenya.

Next steps include looking at the referral system and the network of support to improve adherence support programmes as well as better integration with other services such as TB, prevention of mother-to-child transmission, voluntary counselling and testing, and improved use of data.