Evaluation of the Clinical Impacts and Costs of eHealth in Rwanda Using Innovative Frameworks and Local Capacity Building

Motivation of the study A previous cross sectional analysis of the national HIV program in Rwanda, described the HIV care continuum as a "multitrajectory pathway" with many opportunities for patients to exit and return to care between diagnosis and viral suppression. The authors concluded that the weakest point in the continuum is the transition from diagnosis to linkage to care where only half of newly diagnosed patients link to care within 6 months of receiving their diagnosis.

This study also estimated that 82.2 percent of patients on ART achieve viral suppression. Overall, half of the HIV-positive population in Rwanda in 2013 was assumed to be virally suppressed. This estimate of viral suppression is based on an analysis of EMR data for a subset of 21,995 patients. Correspondence with one of the study authors clarified that 9,680 of these patients were eligible for viral load testing, and 3,066 of eligible patients had recorded viral load data. This suggests that two-thirds of patients eligible for viral load testing do not have viral load results recorded in the EMR. The study do not estimate any type of treatment failure (virologic, immunologic, clinical), and investigators are not aware of any such estimates for Rwanda.

Studies in Botswana, Malawi, Uganda, South Africa, and Cameroon found that 15 to 25 percent of patients had recorded plasma HIV RNA concentrations in excess of 400 copies per mL within 3 years of starting first-line ART. More recently, kenyan study found that among a large cohort of Kenyan patients on ART, 11.6 percent had evidence of immunological treatment failure during the 12-month study period.

In the Kenya study, investigators randomised 7 of 13 clinics using EMRs to an intervention group that received alerts and reminders about immunological treatment failure. The rate of appropriate clinical action in response to treatment failure increased from 30 percent in the control group to 54 percent in the intervention group. The authors also reported a 72 percent relative reduction in the time from the detection of treatment failure to appropriate clinical action. Investigators did not estimate the impact of the CDSS on treatment outcomes such as viral suppression and survival.

With the proposed study in Rwanda, investigators see an opportunity to use low-cost decision support tools to increase the rate of linkage to care from diagnosis, improve data quality and completeness for laboratory data such as viral load, demonstrate the efficacy of these decision support tools for prompting timely clinical intervention following treatment failure, and demonstrate that early intervention can lead to positive clinical outcomes for patients.