CLINICIAN ADHERENCE TO TENOFOVIR-PRESCRIPTION-GUIDELINES FOR HIV POSITIVE PATIENTS WITH IMPAIRED RENAL FUNCTION AT A SPECIALIZED HIV CLINIC IN KAMPALA, UGANDA.

Abstract

Introduction: Tenofovir Disproxil Fumarate (TDF), a highly efficacious drug widely used as first line antiretroviral therapy (ART), is associated with impaired renal function that mostly resolves after substitution. Uganda’s Human Immune Deficiency (HIV) treatment guidelines recommend TDF withdrawal or substitution in patients with estimated Glomerular Filtration Rate (eGFR) less than 60mL/min. We assessed TDF prescription practices, adherence to the guidelines among clinicians who prescribe ART for HIV positive patients with eGFR<60mL/min at a specialized public HIV clinic in Kampala and identified facilitators and barriers for clinician adherence.

Methods: In this mixed methods study with retrospective cross-sectional review of patients’ records and key informant interviews guided by the Capability Opportunity Motivation determine Behavior (COM-B) model, records of consecutive HIV positive patients with eGFR < 60ml/min (calculated using Cockcroft-Gault formula) were reviewed and 12 health workers interviewed. Prescription practices (TDF withdrawal, substitution, and continued prescription) were summarized as proportions with 95%confindence interval (CI). Thematic analysis was done for the qualitative data.

Results: We reviewed records of 357 patients with eGFR <60ml/min started on ART between 2012 and 2017. Median age was 37(IQR 30-45), 213 (59.7%) were female and 336(94.1%) had eGFR of 30-59ml/min/1.732. 166(46.5%) 95% CI 41.3-51.7)) had a prescription of TDF, contrary to guidelines and TDF was substituted at the next visit in only four (2.4%). Overall clinician adherence to the guidelines was low at 54.6% (95%CI 49.4-59.8). Knowledge of guidelines, a pinned up eGFR formula in clinical rooms and observing peers following guidelines were important facilitators. Dependence on clinical signs, frequent stock-outs of laboratory reagents, inadequate knowledge of renal function assessment and absent guidelines on frequency of renal function assessment were important barriers.

Conclusion: Inappropriate TDF prescription in patients with impaired renal function is common in public specialized HIV clinics in Uganda. Dependence on clinical signs before screening, frequent stock outs of laboratory reagents and absent guidelines on indications and frequency of renal function assessment are important barriers