AHRI.TIER.NET.Patients on Dolutegravir-containing regimen.2023

TIER.net is an electronic patient management system that is used for monitoring and evaluation of HIV care and treatment programmes in government health facilities throughout South Africa. The system was designed as part of a 3-tier approach to implementing a full electronic medical records (EMR) system. This approach provides a flexible solution that allows facilities to transition towards EMR in stages, as their infrastructure improves, and resources become available. TIER.net forms the second tier, whereby patient's paper clinical records are entered into a non-networked computer at the health facility and transferred periodically to a central database.

The TIER.net database contains information on clinic visit attendance, laboratory results and ART dispensing records for all patients on ART. The system was implemented in uMkhanyakude district in 2013; patient records from all visits before 2013 were back-captured into the system. AHRI has a memorandum of agreement with the Department of Health to receive the TIER.net data for the 17 clinics in the Hlabisa health sub-district and Hlabisa hospital. A dedicated data entry clerk based in each clinic enters information from patients' paper clinical records into the TIER.net system after each patient visit. Laboratory results are manually entered into TIER.net after they have been received by the clinic (i.e. are not imported electronically from the National Health Laboratory Service (NHLS) system).
Currently, pre-ART visits are not recorded in TIER.net, although modules to capture HIV testing and pre-ART care may be implemented in the future.

AHRI's new clinical database - ACCDB (Africa Centre Clinical Database)
TIER.net has been integrated with AHRI's previous HIV care clinical database (ARTemis), which contains records for HIV positive patients in care at 7 clinics in the sub-district, to create a new combined clinical database, ACCDB. The ACCDB contains clinical records for all HIV positive patients on ART since 2004, when the Hlabisa HIV treatment and Care programme was implemented. Linkage between the two databases is based on personal identifiers, using algorithms developed at AHRI.
The patient records in ARTemis were captured prospectively by AHRI clinical staff from 2004 until 2012, whereas records from this period were back-captured into TIER.net. Therefore, the information in ARTemis pre-2013 was used to fill in missing data in TIER.net, with the following decision rules:
Patients who had records in TIER.net and not in ARTemis: All information retained
Patients who had records in ARTemis but not in TIER.net: No pre-ART records retained (TIER.net only contains records after ART initiation, whereas ARTemis also captured pre-ART information). Retained in new database if the patient started ART and died, transferred out, or was lost to follow-up before 2013.
Patients on ART with records in ARTemis from 2013 onwards, but no record in TIER, were assumed to be a result of a linkage mismatch and were not retained.

Patients who had records in both TIER.net and ARTemis: Visit records from TIER.net only (i.e. visits records from ARTemis are not combined with those in TIER). Laboratory results from ARTemis up to 2013 are combined with results in TIER
The new clinical database has been linked with the AHRI population surveillance database (ACDIS) and the Hlabisa hospital admissions database (HIS). A longitudinal analysis of the HIV care cascade (Haber et al. From HIV infection to therapeutic response: a population-based longitudinal HIV cascade-of-care study in KwaZulu-Natal, South Africa. Lancet HIV 2017; 4(5):e223-e230) has been rerun on the new combined TIER.net and ARTemis data, and results are consistent with those obtained from the ARTemis data alone (although the pre-ART stages must be excluded).
TIER.net data are transferred to AHRI from the central Department of Health on a monthly basis and integrated into ACCDB bi-annually, and the linkages with ACDIS and HIS are updated. (The linkage with the ARTemis database is not re-run since this database is no longer active).
In April 2017, there were >47,000 individuals on ART in the TIER database, of whom approximately 12,000 were linked to ACDIS and 6500 were linked to HIS.
Although TIER.Net data has been included up to July 2017, the current dataset should be analysed only up to end 2016, because it has been linked to the Dec 2016 analytical database. The updated ACCDB data for 2017 will be available towards the end of the first quarter of 2018, linked to the end of 2017 analytical database relase.