Early antiretroviral therapy initiation: access and equity of viral load testing for HIV treatment monitoring

Abstract

Scaling up access to HIV viral load testing for individuals undergoing antiretroviral therapy in low-resource settings is a global health priority, as emphasised by research showing the benefits of suppressed viral load for the individual and the whole population. Historically, large-scale diagnostic test implementation has been slow and incomplete because of service delivery and other challenges. Building on lessons from the past, in this Personal View we propose a new framework to accelerate viral load scale-up and ensure equitable access to this essential test. The framework includes the following steps: (1) ensuring adequate financial investment in scaling up this test; (2) achieving pricing agreements and consolidating procurement to lower prices of the test; (3) strengthening functional tiered laboratory networks and systems to expand access to reliable, high-quality testing across countries; (4) strengthening national leadership, with prioritisation of laboratory services; and (5) demand creation and uptake of test results by clinicians, nurses, and patients, which will be vital in ensuring viral load tests are appropriately used to improve the quality of care. The use of dried blood spots to stabilise and ship samples from clinics to laboratories, and the use of point-of-care diagnostic tests, will also be important for ensuring access, especially in settings with reduced laboratory capacity. For countries that have just started to scale up viral load testing, lessons can be learnt from countries such as Botswana, Brazil, South Africa, and Thailand, which have already established viral load programmes. This framework might be useful for guiding the implementation of viral load with the aim of achieving the new global HIV 90-90-90 goals by 2020.

Development of an algorithm for determination of the likelihood of virological failure in HIV-positive adults receiving antiretroviral therapy in decentralized care

“…However, due to limited capacity of such devices, a combination with central, high-volume testing is still needed [40]. Algorithms such as the VLTC could be considered for determination of subjects at highest risk of VF that should be for point-of-care testing, whereas remaining samples are sent to central laboratories.…”

Point‐of‐care viral load monitoring: outcomes from a decentralized HIV programme in Malawi

“…Knowing their VL status can motivate patients to adhere to treatment [9,10], and can allocate virally suppressed patients into differentiated models of care [11,12]. Yet despite being associated with better treatment outcomes and the prevention of acquired drug resistance [6,13], routine VL-monitoring remains under-utilized in resource-limited settings [14][15][16][17][18][19][20][21]. It was estimated that less than 50% of people on ART in resource-limited settings received an annual VL test in 2017 [22].The test's cost and complexity remain barriers to its use, as does a lack of understanding by some clinicians about VL's long-term patient benefits and its role in prolonging the longevity of treatment regimens [18,21].…”

Supporting Quality Data Systems: Lessons Learned From Early Implementation Of Routine Viral Load Monitoring At A Large Clinic In Lilongwe, Malawi

“…Successful results reporting of viral load relies on collection of accurate identifying patient information and systems for transferring data from central laboratories to health facilities and patient charts 8,9,7 . We performed a small quality improvement assessment of the existing viral load program at Partners in Hope (PIH), a large, urban HIV clinic in Lilongwe, Malawi.…”