Table 2. Problems with ART delivery at an HIV clinic, Guinea-Bissau, 2005–2013.
| Problem | Effect | Solution |
|---|---|---|
| Inadequate drug supply | Patients with a high CD4+ T-lymphocyte count experienced Stevens–Johnson syndrome on switching from efavirenz to nevirapine after stocks of efavirenz ran out;8 development of drug resistance due to treatment interruptions | Improve stock management, increase investment in health-care infrastructure and capacity |
| Clinic relocation | Patients lost to follow-up | Increase the focus on HIV infection at the hospital to give the disease a higher priority among policy-makers |
| Widespread loss to follow-up | Patients not adequately treated | Identify risk factors for patients being lost to follow-up so that effort can be focused on the most vulnerable;9 introduce educational activities for patients to improve health literacy; telephone patients who are late for appointments; visit patients lost to follow-up at home |
| Poor treatment adherence | Treatment failure and drug resistance | Identify risk factors for poor adherence;10 improve health literacy |
| Laboratory inadequacies | ||
| Inadequate validation of HIV rapid tests | Errors in discriminating between infection with HIV-1, HIV-2 and both HIV-1 and HIV-2 occurred with the SD Bioline HIV 1/2 3.0 rapid test (Standard Diagnostics Inc., Yongin, Republic of Korea);11 ineffective treatment for HIV-2 infection using non-nucleotide reverse transcriptase inhibitors; expensive treatment for HIV-1 infection using protease inhibitors | Use other rapid HIV diagnostic tests |
| Temporary unavailability of biochemical tests and CD4+ T-cell count measurements | Delayed initiation of ART; late diagnosis of treatment failure; adverse events not diagnosed | Increase awareness of possible treatment failure |
| No HIV-RNA monitoring | Late diagnosis of treatment failure; development of drug resistance | Increase the ability of the laboratory to perform HIV-RNA measurements |
| Insufficient tuberculosis screening | Tuberculosis not diagnosed, leading to no tuberculosis treatment and increased mortality; no detection of drug-resistant tuberculosis | Introduce a simple clinical tuberculosis score together with a rapid urine test for the disease; introduce tuberculosis culture and drug-resistance tests |
| Insufficient hepatitis screening | No hepatitis treatment due to low sensitivity of rapid tests for hepatitis B and C viruses12 | Increase awareness of the limitations of rapid tests |
ART: antiretroviral therapy; CD4: cluster of differentiation 4; HIV: human immunodeficiency virus; RNA: ribonucleic acid.